Accommodation Standards and Licensing - Alberta.ca · 2017. 4. 11. · Alberta Health Revision 5 Accommodation Standards and Licensing Information Guide Section 1 _____ © 2010-2015

Alberta Health

Accommodation Standards and Licensing

Information Guide Long-term Care Section 7-10 Only

(see http://www.health.alberta.ca/services/continuing-care-forms.htm for the entire Guide)

Compliance and Monitoring

October 2015

http://www.health.alberta.ca/services/continuing-care-forms.html

Alberta Health Revision 5 Accommodation Standards and Licensing Information Guide Section 1

_________________________________________________________________________________________________© 2010-2015 Government of Alberta Introduction 1

Accommodation Standards and Licensing Information Guide This guide provides explanations and resources related to Alberta’s Supportive Living Accommodation Licensing Act, Supportive Living Accommodation Licensing Regulation

and Long-term Care Accommodation Standards.

Revision 5: October 2015 For further information about accommodation standards, contact:

Compliance and Monitoring Branch Alberta Health 10025 Jasper Avenue NW PO Box 1360 Stn. Main Edmonton, Alberta T5J 2N3

Phone 780-644-8428 (310-0000 Toll free) Fax 780-644-8729

This document is also located on-line at: http://www.health.alberta.ca/services/continuing-care-forms.html Full versions of the Supportive Living Accommodation Licensing Act and the Supportive Living Accommodation Licensing Regulation can be accessed from Queen’s Printer on-line at: www.qp.alberta.ca


http://www.qp.alberta.ca/



About the Table of Contents

Page numbers provided are in the format of Section Number – Standard number (if

applicable) – page number. When looking within the document, section numbers are found

at the top of the page (header) and standard and page numbers are found on the bottom of

the page (footer). If viewing on-line CTRL-clicking on any table of contents topic will bring

you to that page.

Example: 2-16 Example: 4-12-1

The first number refers to the Section of the Information Guide located at the top of each page. The second number refers to the subsection number or where there is no subsection the page number. The third number refers to the page number in each subsection.



Table of Contents

Accommodation Standards and Licensing Information Guide ___________________ 1-1

About this Guide __________________________________________________________ 1-5

Questions and Concerns ____________________________________________________ 1-5

A Note on Terminology _____________________________________________________ 1-6

Updates _________________________________________________________________ 1-7

Long-term Care Introduction _____________________________________________ 8-1

Definitions _______________________________________________________________ 8-2

Applicability ______________________________________________________________ 8-2

Purpose _________________________________________________________________ 8-2

Procedure________________________________________________________________ 8-3

Certificate Required _______________________________________________________ 8-3

Initial Certificate Application Process __________________________________________ 8-4

Change in Contact Persons __________________________________________________ 8-4

Certificates Issued _________________________________________________________ 8-5

Public Reporting __________________________________________________________ 8-7

Renewal of a Certificate ____________________________________________________ 8-7

Monitoring Visits __________________________________________________________ 8-8

Concern Resolution Process _________________________________________________ 8-8

Complaints _______________________________________________________________ 8-9

Investigations ____________________________________________________________ 8-9

Standards ________________________________________________________________ 8-9

Comparison to Supportive Living Accommodation Standards _____________________ 8-10

Review Date _____________________________________________________________ 8-10

Coming into Force ________________________________________________________ 8-10

Long-term Care Accommodation Standards _________________________________ 9-1

How to Use this Section ____________________________________________________ 9-2

Standard 1: Building Code Requirements ______________________________________ 9-1-1

Standard 2: Safety Requirements ____________________________________________ 9-2-1

Standard 3: Maintenance Requirements ______________________________________ 9-3-1

Standard 4: Environmental Requirements _____________________________________ 9-4-1

Standard 5: Personalizing Spaces ____________________________________________ 9-5-1

Standard 6: Window Coverings ______________________________________________ 9-6-1



Standard 7: Bedding ______________________________________________________ 9-7-1

Standard 8: Personal Laundry Services ________________________________________ 9-8-1

Standard 9: Personal Choice Services _________________________________________ 9-9-1

Standard 10: Insurance ___________________________________________________ 9-10-1

Standard 11: Contracted Services ___________________________________________ 9-11-1

Standard 12: Social or Leisure Activities ______________________________________ 9-12-1

Standard 13: Nutritional Requirements ______________________________________ 9-13-1

Standard 14: Menu Requirements __________________________________________ 9-14-1

Standard 15: Cleaning Requirements ________________________________________ 9-15-1

Standard 16: Continuation of Services _______________________________________ 9-16-1

Standard 17: Prevention of Abuse __________________________________________ 9-17-1

Standard 18: Resident Safety and Security ___________________________________ 9-18-1

Standard 19: Trust Accounts _______________________________________________ 9-19-1

Standard 20: Corporate Status _____________________________________________ 9-20-1

Standard 21: Water Temperature ___________________________________________ 9-21-1

Standard 22: General Information __________________________________________ 9-22-1

Standard 23: Information Respecting the Long-term Care Accommodation _________ 9-23-1

Standard 24: Concerns and Complaints ______________________________________ 9-24-1

Standard 25: Certificate Posted ____________________________________________ 9-25-1

Standard 26: Criminal Record Checks ________________________________________ 9-26-1

Standard 27: Privacy and Personal Information _______________________________ 9-27-1

Standard 28: Safety and Security ___________________________________________ 9-28-1

Standard 29: Job Descriptions ______________________________________________ 9-29-1

Standard 30: Residents’ Personal Affairs _____________________________________ 9-30-1

Long-term Care Resources ______________________________________________ 10-1

Forms _______________________________________________________________ 7-1

Reportable Incidents _______________________________________________________ 7-1



About this Guide This information guide is intended for operators of supportive living and long-term care

accommodations and staff employed by the Ministry of Health who license supportive living

accommodations and monitor long-term care accommodations. The information contained

within will provide explanation and rationales on the Supportive Living Accommodation Licensing

Act and Regulation, as well as information to assist both supportive living and long-term care

operators to comply with provincial accommodation standards.

Questions and Concerns

Any questions or concerns about the standards or information contained in this guide can be

directed to [email protected]

mailto:[email protected]



A Note on Terminology The Act refers to the Supportive Living Accommodation Licensing Act unless otherwise specified.

The Regulation refers to the Supportive Living Accommodation Licensing Regulation.

The Standards refers to Schedule 1 of the Supportive Living Accommodation Licensing

Regulation.

The Ministry refers to Alberta Health.

Accommodation refers to buildings or units in buildings where accommodation related

services (cleaning, maintenance, food services, etc.) are offered or provided to the residents.

Examples of accommodations may include, but are not limited to: supportive living

accommodations, long-term care accommodations and auxiliary hospitals.

Resident refers to the individual that resides in an accommodation.

Employee refers to employees of an operator who provide accommodation services, but

does not include health care professionals.

Operator refers to the person responsible for the operation of the accommodation.

Policy refers to an overall written plan, principle or guideline used in an accommodation.



Updates The Accommodation Standards and Licensing Information Guide is available on-line at

http://www.health.alberta.ca/services/continuing-care-forms.html.

The contents of this guide are revised and updated as additional information and resources

are collected. Updates will also be provided on-line and e-mails will be sent to operators

when updates are available.

Record of Information Guide Amendments Amendment No.

Dated (M/D/Y)

Pages to be replaced Entered by Date

Revision 1 04/01/10 3-6, 9, 41, 43, 49, 51, 97-147, 166-195

Revision 2 05/14/10 3-6, 9, 78, 109, 116, 117, 137, 160, 161, 169-174, 194-324

Revision 3 04/01/11 All – copies provided by ASCS (1 per accommodation)

Revision 4 03/28/13 All pages affected by style update Content changed as per Version Tracking #4

Revision 5 10/05/15 Content changed as per Version Tracking #5



_________________________________________________________________________________________________© 2010-2015 Government of Alberta


_________________________________________________________________________________________________ © 2010-2015 Government of Alberta LTC Introduction 1

Long-term Care Introduction In this section information is provided on the authority and process used by Alberta Health to monitor long-term care accommodations to the Long-term Care Accommodation Standards.

In This Section

Definitions 2

Applicability 2

Purpose 2

Procedure 3

Certificate Required 3

Initial Certificate Application Process 4

Change in Contact Persons 4

Certificate Issued 5

Multiple Year Certificate Criteria 6

Certificates with Conditions 7

Public Reporting 7

Renewal of a Certificate 7

Monitoring Visits 8

Concern Resolution Process 8

Complaints 9

Investigations 9

Standards 9

Comparison to Supportive Living Accommodation Standards 10

Review Date 10

Coming into Force 10



Definitions

Definitions are provided for terminology that is utilized in this section of the Information

Guide.

□ Certificate: a certificate issued by Alberta Health which identifies the long-term care

accommodations status of compliance with the long-term care accommodation

standards.

□ Director: the director of the Continuing Care Standards and Licensing Unit.

□ Legal representative: a guardian or surrogate decision-maker of a resident pursuant

to a court order.

□ Long-term care accommodation: a “nursing home” under the Nursing Homes Act is

defined as a facility for the provision of nursing home care; or an “auxiliary hospital”

under the Hospitals Act is defined as a hospital for the treatment of a long-term care

or chronic illnesses, diseases or infirmities.

□ Minister: the Minister of Alberta Health.

□ Ministry: Alberta Health

□ Operator: a person who operates a long-term care accommodation.

Applicability

The Long-term Care Accommodation Standards apply to all long-term care

accommodations in Alberta. The governing legislation for the accommodation standards is

the Nursing Homes General Regulation, section 4(2)(b).

Purpose

The purpose of the long-term care accommodation standards is:

□ to verify that operators of long-term care accommodations meet minimum standards

to ensure the safety and well-being of the individuals living in the accommodation

and

□ to provide public assurance of the quality of long-term care accommodations.



Procedure

Long-term care accommodations are monitored to their compliance with the Long-term

Care Accommodation Standards. Certificates are issued by the Compliance and Monitoring

Branch after a monitoring visit has occurred. Certificates indicate if the accommodation is

in full compliance or if there are any non-compliances to be rectified within a specified time

period.

Results of monitoring visits completed at long-term care accommodations are forwarded to

Alberta Health Services. Alberta Health Services may be requested to assist the operator in

achieving compliance to the Long-term Care Accommodation Standards.

Certificate Required

An operator must have certificate for each location at which the operator provides long-term

care accommodations.

If there are conditions on a certificate the operator must comply with these conditions of the

certificate.

As required in standard 25 an operator must post the certificate in a prominent place in the

long-term care accommodation to which it pertains.

A certificate is not transferable. If there is a change in the operator, the location or there is a

substantial change in operations the accommodation, the operator will need to notify the

Compliance and Monitoring Branch.

The certificate indicates that the operator is either in full compliance to the accommodation

standards or not in full compliance by identifying the non-compliant standards. It is easily

recognizable and provides assurances to the residents, family members, general public,

stakeholders, funders and other organizations that the minimum standard of

accommodation and accommodation- related services have been met.



Initial Certificate Application Process Operators that have obtained a contract with Alberta Health Services for the provision of

long-term care services must obtain a certificate for each accommodation where this service

is provided. A long-term care certificate application form is available on-line at:

https://cfr.forms.gov.ab.ca/form/SCF0005.pdf

It is the responsibility of the operator to collect the required documentation for submission.

The following documentation is required:

Application form,

Confirmation of current general liability insurance coverage,

A copy of the most recent environmental health report,

A copy of safety code approval for a new or renovated long term care

accommodation,

A copy of zoning approval.

At any time during the application process, an operator may request a consultation by a

Licensing Inspector, to review the monitoring process and the accommodation standards.

Upon receipt of all collateral documentation, an initial monitoring visit will be scheduled,

where all accommodation standards will be reviewed. During the initial visit, operators are

expected to demonstrate through the readiness of the environment, staffing, supplies and

written documentation that the accommodation is immediately suitable for residency.

Change in Contact Persons

Any changes to operator or accommodation contacts should be communicated to the

Compliance and Monitoring Branch as soon as the change occurs. Contact information is

utilized to schedule inspections, investigations, follow up on incident reports and send

application and public reporting notifications.




Certificates Issued The duration of an accommodation’s certificate is determined at the discretion of the director based upon the outcome of monitoring visits and investigations. New accommodations:

New accommodations that are compliant or non-compliant to the accommodation standards may be issued a certificate for up to a six month period.

New accommodations that have been fully compliant to the accommodation standards for six months and have received no confirmed complaints in that six month period are eligible for a certificate of up to one year.

New accommodations that have not been fully compliant to the accommodation standards for six months or have received confirmed complaints in that six month period are eligible for a certificate of up to six months.

After the completion of the first year of certification and previously monitored accommodations:

Accommodations that have been fully compliant to the accommodation standards for less than one year, or have received confirmed complaints are eligible for a certificate of up to a one year period only.

Accommodations that have been fully compliant to the accommodation standards and have received no confirmed complaints for one year are eligible for a certificate of up to a two year period.

Accommodations that have been fully compliant to the accommodation standards and have received no confirmed complaints for three years (1 year + 2 year certificate or 3 year certificate) are eligible for a certificate of up to a three year period.

The duration of the certificate does not dictate the time between monitoring visits. Operators can expect periodic announced or unannounced monitoring visits throughout their certificate period. At a minimum a mini-monitor will occur annually to review compliance with standards related to the safety and security of residents.



Multiple Year Certificate Criteria

Examples for determining how multiple year certificate duration criteria will be applied (not applicable for new accommodations): Accommodation A receives annual monitoring visits in April of each year. It is fully compliant at each of the monitoring visits and has no confirmed complaints. It is eligible for multi-year certification. Upon completion of a three year certificate, operators that continue to meet the compliance requirements are eligible for ongoing 3 year certificates.

Monitor

Type

Monitoring

Date

Non-

Compliances

Confirmed

Complaints

Certificate

Type

Certificate

Expiry

Full April 2010 No No Full April 30, 2011


Mini April 2012 No No N/A N/A





Accommodation B receives annual monitoring visits in May. It was not fully compliant in the first year of monitoring, but became fully compliant in the second year of monitoring. Note that eligibility for multi-year certification is affected for one year only.

Monitor Type

Monitoring Date

Non-Compliances

Confirmed Complaints

Certificate Type

Certificate Expiry

Full May 2010 Yes No Conditional Negotiated Date

Full May 2011 No No Full May 31, 2012


Mini May 2013 No No N/A N/A


Accommodation C receives annual monitoring visits in June. It was fully complaint in the

first and second year of monitoring, but later was found to be non-complaint. Note that

once Accommodation C is found to be non-compliant a mini-monitor will become a full

monitor. Upon certificate expiry Accommodation C is returned to a one-year certificate term

as they no longer meet the eligibility criteria for multi-year certification.

Monitor

Type

Monitoring

Date

Non-

Compliances

Confirmed

Complaints

Certificate

Type

Certificate

Expiry

Full June 2010 No No Full June 30, 2011


Mini ->

Full

June 2012 Yes No N/A N/A

Follow-up visit to occur as necessary to rectify non-compliances.




Certificates with Conditions

Certificates with conditions may be issued to accommodations that do not meet certain accommodation standards while the conditions are being rectified. In situations in which the operator is unable or unwilling to comply, the residents are at risk, or the conditions of a certificate are not being addressed by the operator Alberta Health will work in conjunction with Alberta Health Services to determine the appropriate action to ensure compliance and resident safety.

Public Reporting The status of an accommodation’s certificate is posted on the Alberta Health Public

Reporting website located at http://standardsandlicensing.alberta.ca/.

The public reporting system displays all visits completed at an accommodation and all non-

compliances issued, in progress and rectified during those visits completed since April 1,

2013.

All visit types are reported on the public reporting website including annual inspection visits,

complaint investigations, follow up visits and consultations. Any non-compliance issued to

the accommodation will be posted, regardless of the duration of time to rectify the non-

compliance. Non-compliance information will include both the date the non-compliance was

issued and the date that it was rectified, or the planned date of completion if it is still in

progress.

The public reporting system is updated continuously throughout the day, however,

information on visits completed and non-compliances issued and rectified may not be

displayed for up to three business days.

Renewal of a Certificate Approximately four to six weeks prior to the long-term care accommodation’s certificate

expiry date a Licensing Inspector will contact the long-term care accommodation operator to

schedule a monitoring visit.

http://standardsandlicensing.alberta.ca/



Monitoring Visits

An inspector may, with the permission of the operator of a long-term care accommodation,

□ At any reasonable hour enter the long-term care accommodation and inspect that

long-term care accommodation;

□ Require the production of any books, records or other documents in respect of the

long-term care accommodation;

□ Interview the operator of the long-term care accommodation with respect to matters

relevant to the inspection.

□ An inspector may enter the long-term care accommodation of a particular resident

only with the permission of that resident or that resident’s legal representative.

□ An inspector may interview employees and residents of the long-term care

accommodation, relatives of residents, legal representatives of residents and any

other person who may have information relevant to the monitor or investigation.

Concern Resolution Process Operators concerned with a decision of a Licensing Inspector in regards to the issuance of a non-compliance to the accommodation standards as a result of a monitoring visit or investigation may bring their concern to the attention of the Director. To commence the concerns resolution process the operator must provide in writing within 10 working days of the non-compliance being issued the following information:

The specific issue or non-compliance being disputed. The evidence that was presented to the Licensing Inspector to demonstrate

compliance. The grounds on which operator believes the non-compliance or findings of an

investigation to be inaccurate. Upon receipt of this information, the Director will delegate the Manager, Licensing Services and the Licensing Supervisor to review the decision utilizing the provided information. Their recommendation will be reviewed by the Director, who may confirm, vary or rescind the decision that has been received. The Director will provide the operator with the results of the decision and the reasons for the decision in writing within 30 days of the receipt of the concern. The Director’s decision is final.



Complaints Concerned individuals are encouraged to follow the documented concerns or complaints resolution process of the long-term care accommodation. Where complaints are related to a non-compliance to the Long-term Care Accommodation Standards, the concerned individuals have the option of directing complaints to the Complaints Officer of the Compliance and Monitoring Branch. The Complaints Officer may refer the complaint to investigation, refer the complaint to another authority, or refuse to refer the complaint if it is deemed to be resolved, frivolous or vexatious.

Investigations All complaints that have been referred for investigation will be investigated by a Licensing Inspector. Investigation visits may occur on an announced or an unannounced basis, as per the discretion of the investigator and the Complaints Officer. Entering the long-term care accommodation and investigating an allegation of non-compliance identifies the validity of the complaint. This ensures that operators are maintaining compliance to the standards throughout their certification period. Results of the investigation are shared with the operator at the time of the investigation.

Standards The standards identify the requirements that long-term care operators must comply with when operating a long-term care accommodations. These standards are outlined in Section 9 of this Information Guide.



Comparison to Supportive Living Accommodation Standards There are 30 Long-Term Care Accommodation Standards compared to 32 Supportive Living Accommodation Standards. The differences are:

□ Four additional standards for long-term care accommodations. o Personal laundry services are required in long-term care as opposed to

optional in supportive living. o Posting Certificates of Compliance is a requirement in the Supportive Living

Accommodation Licensing Act. o Insurance is a requirement in the Supportive Living Accommodation Licensing

Regulation. o Corporate Status is a requirement in the Supportive Living Accommodation

Licensing Regulation.

□ Six supportive living accommodation standards are not relevant for long-term care accommodations:

o Assessment (in long-term care this is the responsibility of centralized intake not the operator).

o Reassessment (in long-term care this is the responsibility of centralized intake not the operator).

o Risk management (in long-term care this is the responsibility of centralized intake not the operator).

o Medication assistance and reminders (in long-term care this is the responsibility of Alberta Health Services and monitored under the Continuing Care Health Service Standards).

o Laundry services for resident-supplied bedding and towels is not applicable in long-term care as bedding is required to be supplied by operators.

o Safeguarding of personal possessions was removed as this duplicates a requirement under the Nursing Home Operational Regulation.

Review Date To ensure the Standards are reviewed for ongoing relevancy, a review date has been established for March 31, 2017.

Coming into Force These Long-term Care Accommodation Standards will come into force on April 1, 2010.


_________________________________________________________________________________________________ © 2010-2015 Government of Alberta LTC Standards 1

Long-term Care Accommodation Standards In this section the Long-term Care Accommodation Standards are explained with additional information to guide in the adherence to the standards.

In This Section

Standards – Each standard is broken down and numbered consecutively from 1. Standard and page numbers are found in the bottom right hand corner of each page. Standard 1: Building Code Requirements

Standard 2: Safety Requirements

Standard 3: Maintenance Requirements

Standard 4: Environmental Requirements

Standard 5: Personalizing Spaces

Standard 6: Window Coverings

Standard 7: Bedding

Standard 8: Personal Laundry Services

Standard 9: Personal Choice Services

Standard 10: Insurance

Standard 11: Contracted Services

Standard 12: Social or Leisure Activities

Standard 13: Nutritional Requirements

Standard 14: Menu Requirements

Standard 15: Cleaning Requirements

Standard 16: Continuation of Services

Standard 17: Prevention of Abuse

Standard 18: Resident Safety and Security

Standard 19: Trust Accounts

Standard 20: Corporate Status

Standard 21: Water Temperature

Standard 22: General Information

Standard 23: Information Respecting the Long-term Care Accommodation

Standard 24: Concerns and Complaints

Standard 25: Certificate Posted

Standard 26: Criminal Record Checks

Standard 27: Privacy and Personal Information

Standard 28: Safety and Security

Standard 29: Job Descriptions

Standard 30: Residents’ Personal Affairs



How to Use this Section Each standard of the Long-term Care Accommodation Standards includes an intent

statement to provide additional information regarding the rationale behind the creation of

the standard, definitions to provide additional information as to the usage of some words or

phrases within the section, as well as the standard itself.

Each standard is then explained within the categories of ‘Methods of Compliance’ and

‘Evidence of Compliance’. Some standards are best explained by breaking them into separate

topics. For example, ‘maintenance requirements’ includes a section on preventative

maintenance and corrective maintenance (see example below). Evidence from each of the

sections is necessary to be compliant to the standard.

In some cases the standard or a section of a standard may not be applicable to an

accommodation. This may occur where the operator does not provide that optional service

(e.g. personal choice services) or where there have been no changes made to the

accommodation (e.g. building code requirements).

For each section one or more possible methods and evidence types are provided. The

methods and evidence types are not meant to be exhaustive, but rather to give the range of

methods of compliance that are currently utilized by long-term care accommodation

operators. The method and evidence chosen by an operator will need to suit the population

and level of service provided.

Example of format to follow on next page:

3(2) An operator shall develop, maintain and implement a scheduled preventative maintenance and repair program to inspect the condition of the long-term care accommodation, the building that houses it and its equipment and operator-owned furnishings and ensure that repairs, service and, where applicable, replacements are provided as needed.

Preventative Maintenance

Methods of Compliance (possible, but not limited to):

Evidence of Compliance (possible, but not limited to):

Preventative maintenance program for the building, the accommodation, its equipment, and any operator-owned furnishings is in a paper based format.

Documentation demonstrating a regularly scheduled preventative maintenance program is implemented. This information may be found in logbook(s), checklist(s), calendar(s), filing system(s), bring forward system(s) or other preventative maintenance program(s).

Corrective Maintenance



Repairs, service and replacement of buildings, equipment and operator-owned furnishings is completed using a requisition process.

Conversations with residents and employees regarding timely completion of repairs and replacements.

Documentation demonstrating that repairs and replacements occur as needed. This information may be found in communication book(s), email(s), form(s), computerized request(s) or other requisition format.



Definitions

Conversations: informal conversations may occur between the Licensing

Inspector and residents, their representatives, employees, volunteers, service

providers or the operator.

Observation: the Licensing Inspector will tour the accommodation and its

grounds to observe the services in place, the upkeep of the accommodation,

grounds, equipment and furnishings, and the implementation of processes.

Resident rooms will be observed with resident/representative permission only.

Documentation: the Licensing Inspector will review relevant documentation to

determine the operator’s processes and verify implementation. Where

documentation is noted it must be completed consistently and as per the

accommodations specified process.

The population served, type and size of long-term care accommodations varies and as such

the determination of an accommodation’s compliance with the standards is completed at the

discretion of the Compliance and Monitoring Branch.

Laundry Services or Facilities



Residents are informed about the internal laundry service.

Conversations with residents regarding the internal laundry service provided.

Observation of the internal laundry service.

Documentation provided may include handbook(s), orientation material(s), laundry schedule(s) or other resident notice(s).

Residents are informed about the external laundry service.

Conversations with residents regarding the external laundry service.

Documentation provided may include handbook(s), orientation material(s), laundry schedule(s) or other resident notice(s).

Residents are informed about the laundry facilities available on site.

Conversations with residents regarding the laundry facilities.

Observation of the laundry facilities. Documentation provided may include

handbook(s), orientation material(s), laundry schedule(s) or other resident notice(s).

Only one method of compliance is necessary, but some sites may offer multiple levels of service, so they may fall into more than one method.

The evidence provided must coincide with the method chosen. There are a variety of ways in which to provide the evidence, all possible ways are not required. Combinations of or singular evidence types may be sufficient for compliance.




_________________________________________________________________________________________________ © 2010-2015 Government of Alberta Standard 1 1

Standard 1: Building Code Requirements

Intent

To verify that when changes are made to a long-term care accommodation or the population

changed therein, the long-term care accommodation is compliant with the Alberta Building

Code.

Definitions

Structural changes: any additions or major renovations to the accommodation or

within the accommodation in which a building permit is required. Examples include

basement developments, deck building, building additions, interior restructuring or

the movement of walls.

Change of use: any change to the use of the accommodation or resident population

that is served where a development permit is required. Examples include additions of

a dementia care unit, changes in use of common areas or changes in residents’ ability

to self evacuate due to changes in their abilities or changes in the accommodation

(e.g. addition of a security or emergency call system).

1(1) Any changes that are made to the physical structure of a building that houses a

long-term care accommodation or to the long-term care accommodation itself must

meet the requirements of the Alberta Building Code.

Structural Changes



Where structural changes have been made

to the accommodation there is evidence of

the building continuing to meet the Alberta

Building Code.

Documentation provided may include

a building permit or an occupancy

approval.

1(2) Where changes are made in the use of, or to the population residing in, a building

that houses a long-term care accommodation, the building must continue to meet

the requirements of the Alberta Building Code.

Population Changes



Where the use of the building or the

population residing in the accommodation

has changed there is evidence of the

building continuing to meet the Alberta

Building Code.

Documentation provided may include a

development permit or occupancy

approval.





Standard 2: Safety Requirements

Intent

To verify that the operator maintains the long-term care accommodation in a condition that

is safe and hazard free. Ensuring the long-term care accommodation, building and grounds

remain in good condition allows residents to fully utilize the accommodation and grounds

safely.

Definition

Grounds maintenance – all seasons: the timely completion of ice and snow

removal, standing ground water removal in quick melt conditions, lawn, garden and

pond maintenance, where applicable.

2 An operator must ensure that the building that houses the long-term care

accommodation, the long-term care accommodation itself and its grounds or common

areas are in a safe condition and maintained so as to remain free of hazards.

Safe Condition

Methods of Compliance

(possible, but not limited to):

Evidence of Compliance


The building, the long-term care

accommodation, and the grounds are safe

and hazard free. Essential repairs are

completed within appropriate timeframes.

Hallways, stairways, exits and ramps are

well lit, and kept clear of objects that could

cause falls or obstruct passage.

Hazardous materials (chemicals, sharps,

construction materials) are safely stored.

See also Maintenance Requirements, as

maintenance is a component of ensuring a

safe environment.

Observation of interior and exterior of

the building, the long-term care

accommodation and the grounds.

Documentation demonstrating that

the building, the long-term care

accommodation and the grounds are

maintained in a safe condition. This

information may be found in

contracts, job descriptions, duty lists

or checklists.



Grounds Maintenance ~ All Seasons



Outside grounds maintenance is

completed by maintenance or other

employees.

Conversations with residents, their

representatives or employees

regarding grounds maintenance.

Observation of well maintained

grounds.


grounds maintenance is completed.

This information may be found in job

descriptions, duty lists or checklists.

Outside grounds maintenance is

completed by contract or by an external

service provider.



regarding grounds maintenance.

Observation of well maintained

grounds.


grounds maintenance is completed.

This information may be found in

contracts, service agreements, quotes

or fee schedules.



Standard 3: Maintenance Requirements

Intent

To verify that the operator takes steps to minimize preventable deterioration of buildings,

accommodations, grounds, equipment and operator-owned furnishings. Preventative and

corrective maintenance programs reduce the occurrence and severity of situations which can

compromise resident safety and disrupt the delivery of services.

Definitions

Preventative maintenance: The care and servicing of buildings, accommodations,

equipment and operator-owned furnishings for the purpose of ensuring satisfactory

operating condition by providing for systematic inspection, detection and correction

of incipient failures either before they occur or before they develop into major

defects.

Corrective maintenance: the maintenance which is required when an item or

structure has failed or deteriorated, to bring it back to working order.

Equipment: includes all equipment or machinery used in the accommodation, the

building or the surrounding grounds. Equipment may include heating equipment,

emergency power systems, air conditioning equipment, make-up air equipment,

domestic hot water heating equipment, ceiling lifts, accessibility equipment, elevators,

kitchen and laundry equipment, plumbing and drainage equipment, and grounds

maintenance equipment.

Operator-owned furnishings: includes all furnishings provided by the operator in

common areas, outdoor areas or for use in resident rooms.

3(1) An operator must ensure that the building that houses the long-term care

accommodation, the long-term care accommodation itself and any equipment and

operator-owned furnishings are well maintained and in good working order.

Well Maintained



The building, the long-term care

accommodation, equipment and operator-

owned furnishings are well maintained.

Necessary repairs are completed within

appropriate timeframes.

See also 3(2).

Observation of the building, the long-

term care accommodation itself,

equipment and operator-owned

furnishings.


contracts, job descriptions, duty lists or

checklists.



3(2) An operator shall develop, maintain and implement a scheduled preventative

maintenance and repair program to inspect the condition of the long-term care accommodation, the building that houses it and its equipment and operator-owned furnishings and ensure that repairs, service and, where applicable, replacements are provided as needed.

Preventative Maintenance



Preventative maintenance program for the

building, the accommodation, its

equipment, and any operator-owned

furnishings is in a paper based format.

Documentation demonstrating a

regularly scheduled preventative

maintenance program is implemented.


logbooks, checklists, calendars, filing

systems, bring forward systems,

external equipment inspection reports

or other preventative maintenance

programs.

Preventative maintenance program for the

building, the accommodation, its

equipment, and any operator-owned

furnishings is in a computer based format.

Observation of the preventative

maintenance computerized program.

Documentation demonstrating a

regularly scheduled preventative

maintenance program is implemented.


computer printouts, reports, or other

paper based or electronic logging.



Corrective Maintenance



Repairs, service and replacement of

buildings, accommodations, equipment

and operator-owned furnishings is

completed using a requisition process.


representatives and employees

regarding timely completion of repairs

and replacements.


repairs and replacements occur as

needed. This information may be found

in communication books, emails, forms

or computerized requests.

Repairs, service and replacement of

buildings, accommodations, equipment

and operator-owned furnishings is

completed using external service

providers.


representatives and employees

regarding timely completion of repairs

and replacements.


repairs and replacements occur as

needed. This information may be found

in receipts or invoices.





Standard 4: Environmental Requirements

Intent

To verify that the temperature and ventilation system in a long-term care accommodation

supports the safety and comfort of those who live there. Where a comfortable temperature

level for the majority of residents is not compatible with the safety needs of a particular

resident, measures are taken or mechanisms are put in place to ensure the safety of the

resident while still promoting the comfort of all residents.

Definitions

Comfort of the majority of the residents: resident’s comfort with the temperatures

is not only a result of the physical temperature of the accommodation but may also

be achieved by taking additional steps, such as the introduction of additional fans or

heaters to the environment, adjustment of the clothing worn by the residents or the

activation of a contingency plan.

Reasonable temperature: other legislation exists that provide additional

temperature requirements for accommodations.

o Under the Public Health Act, the Institutions Regulation states: “Every room in an

institution or a day care facility shall be maintained at a minimum temperature of

20 degrees Celsius unless otherwise specified.” (AR 143/81 s10)

o The Alberta Building Code states “Except as permitted by Sentence (1), heating

facilities capable of maintaining an indoor air temperature of 22○C at the outside

winter design temperature shall be provided a) for all sleeping rooms in a care,

treatment or detention occupancy, or b) in a building used for residential

occupancy intended for use in the winter months on a continuing basis” (Alberta

Building Code 2014, Section 6.2.1.14)



4 In a long-term care accommodation where residents are unable to adjust the temperature in their rooms and in the common areas of any long-term care accommodation, the operator shall ensure that heating, cooling and ventilation systems are operated at a level that maintains a temperature that supports the safety of all residents and the comfort of the majority of the residents.

Temperature



Residents have free access to the

thermostat for the accommodation and the

temperature is maintained at a level in

which the majority of residents are

comfortable.

Conversations with residents regarding

their ability to change the temperature

and their overall comfort level in the

accommodation.

Observation of the free access to the

thermostat.


residents are aware that they can

adjust the temperature. This

information may be found in resident

handbooks, memos, posters or

resident meeting minutes.

Residents may not have free access to the

thermostats, but the temperature of the

accommodation is determined by the

majority of resident preferences.

Conversation with residents regarding

their overall comfort level in the

accommodation.

Observation of the temperature of the

accommodation.


consultation with residents occurred to

determine the appropriate temperature

range. This information may be found

in meeting minutes, surveys or

questionnaires.



Temperature (Continued)



Residents may not have free access to the

thermostats, but the temperature of the

accommodation is maintained at a

reasonable setting and the majority of

residents express satisfaction or appear

comfortable with the temperature.

Conversations with residents

regarding their overall comfort level in

the accommodation.

Conversations with employees

regarding how they ensure residents

are comfortable with the temperature.

Observation of the temperature of the

accommodation.

Documentation demonstrating the

monitoring of temperatures of the

accommodation. This information may

be found in log books, preventative

maintenance forms or recordings.





Standard 5: Personalizing Spaces

Intent

To verify that the operator supports the personalization of resident rooms. The residents’

personal space is where residents spend a good deal of time and where some of their most

private activities take place. It is important that residents are comfortable in their personal

space and that operators support residents in creating a space that is familiar and reflects

their individuality.

Definition

Personalization of resident rooms: this may include adding in personal effects

such as pictures, bedding and wall décor or bringing in pieces of furniture.

5 An operator shall ensure that each resident of a long-term care accommodation has

the opportunity to personalize the resident’s room.

Personalization



Personalization of resident rooms is

evident.

Conversations with residents or their

representatives regarding the

opportunity to personalize their room.

Observation of the personalization of

resident’s rooms.

Residents are notified of the ability to

personalize their rooms within specified

parameters, if any. The level of

personalization is dependent on resident

needs, choice and preferences.



opportunity to personalize their room.


resident’s rooms.

Documentation demonstrating that the

resident is notified of their ability to

personalize their room. This

information may be found in meeting

minutes, questionnaires, handbooks,

residential services agreements or

orientation checklists.



Personalization (Continued)



Resident(s) have limitations on their ability

to personalize their rooms due to

documented resident needs or behaviours.


resident’s rooms to the extent possible.


extent of the limitations on the

resident’s personalization of their room.


meeting minutes, managed risk

agreements, assessments or care

plans.



Standard 6: Window Coverings

Intent

Comfort and privacy are supported by the provision of window coverings. Operators are

responsible for providing residents with window coverings in resident rooms and in

common areas where appropriate. Appropriate window coverings promote resident

comfort by protecting the privacy of the resident, contributing to a home-like atmosphere

and also by helping residents control the amount of light entering their personal spaces.

Definition

Appropriate window coverings: coverings that fit the window, are appropriate for

the intended usage, are functional, clean and in good condition.

6 An operator of a long-term care accommodation shall ensure that appropriate

window coverings are provided in the long-term care accommodation as necessary

for the comfort and privacy of the residents, including in each resident’s room.

Window Coverings



Window coverings on each window in the accommodation as necessary for resident’s privacy and comfort are evident.

Observation of the window coverings.





Standard 7: Bedding

Intent

To verify that operators provide clean bedding, towels and linen in the quantity and

frequency to meet the needs of the residents. It is important that bedding, towels or other

linens are changed on a regularly scheduled basis that takes into consideration resident’s

needs, preferences and hygienic concerns.

Definitions

Bedding: any linen, comforter, blanket, or other bed covering provided by the

operator to the resident for their personal use.

Towels: any bath towel, hand towel and face cloth provided by the operator.

Other linens: includes tablecloths and napkins.

7(1) The operator provides bedding, towels or other linens for the use of residents and

shall ensure that they are clean, fresh, dry and in good condition and changed at

least weekly to ensure a clean living environment for each resident.

Quality



Clean, fresh and dry bedding and towels in

good condition are evident.

Conversations with residents or

representatives regarding the quality

of bedding, towels and other linen.

Observation of bedding and towels in

good condition that are stored or

covered in such a way to ensure that

they remain clean, fresh and dry.

Weekly Scheduled Changes



Operator provided bedding, towels and other linens are changed on an at least weekly basis.

Conversations with residents or representatives regarding the weekly bedding, towels and other linen changes.

Observation of implementation of bedding and towel change schedules.

Documentation provided may include bedding and towel change schedules, cleaning schedules, checklists, duty lists, bath schedules, handbooks, resident notices or orientation materials.



7(2) When the operator provides bedding and towels for residents, the operator shall do

so in keeping with the particular needs of each resident.

Quantity



Sufficient quantities of bedding and towels

are evident.


regarding sufficient quantities of

bedding and towels.

Observation of sufficient quantities of

bedding and towels.

The operator has contracts with external

sources for bedding and towel provision.


order forms, invoices, or bedding and

towel tallies.

As Needed Changes



Written procedures showing that operator

provided bedding, towels and other linens

are provided and changed “as needed”.



regarding the “as needed” change of

bedding, towels and other linens.


operator engages in the “as needed”

change of bedding, towels and other

linens. This information may be found

in policies and procedures, duty lists,

bedding and towel tallies, resident

handbooks, service agreements, fee

schedules, log books, linen change

schedules or bed carbolization

tracking sheets.

Operator provided bedding, towels and

other linens are changed “as needed”

based on documented resident need.



regarding “as needed” changes of

bedding, towels and other linens.

Observation of bedding, towel or other

linen changes.

Documentation of the needs of the

residents for bedding, towel and other

linen changes. This information may

be found in care plans, duty lists, logs

or job descriptions.



Standard 8: Personal Laundry Services

Intent

To verify that the operator ensures personal laundry services or facilities are available for

residents and their representatives or service providers. It is important that residents, their

representatives or their service providers have a means to launder their personal items and

garments. Where laundry equipment is provided for residents, their representatives or service

providers to do their own laundry, laundry equipment is maintained in good working order

and the space provided is appropriate for the intended use.

Definition

Personal laundry service: residents’ personal garments, and any bedding, linens or

towel that residents have supplied for their own personal use.

8(1) The operator shall ensure either

a) that personal laundry services are provided, or

b) that personal laundry facilities are made available for residents’ personal

laundry to be done on-site.

Laundry Services or Facilities



An internal personal laundry service is

provided.


regarding the laundry service

provided.

Observation of the internal laundry

service.


handbooks, laundry schedules or

residential service agreements.

Laundry facilities are available on site for

residents’ personal laundry to be done by

the residents, their representatives or their

service providers.


representatives regarding the laundry

facilities.

Observation of the laundry facilities.




An external personal laundry service is

provided.


regarding the external laundry service.






8(2) Where the operator provides laundry equipment for the personal use of residents,

their representatives or their service providers, the operator shall ensure that the

equipment and the laundry area are appropriate, clean and in good repair.

Laundry Areas and Equipment



Resident laundry areas and equipment are

appropriate for their intended use, clean

and maintained in good repair.


representatives regarding the laundry

area and equipment.

Observation of the appropriateness

and cleanliness of laundry areas.


cleaning schedules, duty lists, invoices

or maintenance records.



Standard 9: Personal Choice Services

Intent

To verify that where optional services are available they are provided by qualified persons in

an appropriate space. Personal choice services can enhance the quality of life of residents

and provide convenient access for residents to meet their personal needs.

Definition

Appropriate space: A location away from food service and dining areas that

includes the necessary equipment for the personal choice service and whereby all

hazards (equipment or materials) can be appropriately secured. The space provided

should also safely and comfortably accommodate those residents using the space.

9(1) In this section, “personal choice services” include optional services that may be

provided or offered to residents of a long-term care accommodation such as

hairdressing, barbering, manicures, pedicures, massages and facials.

Personal Choice Services

Personal choice services relate to the provision of a range of optional services that may

be or are acquired at resident’s own expense.

Please note that footcare is not considered a pedicure, as footcare is provided by a

health professional.

In this section, personal choice services exclude those professions covered under the Health Professions Act (e.g. Denturists, Dental Hygienists, Hearing Aid Practitioners, Occupational Therapists, Optometrists, Podiatrists, Registered Dietitians, Speech Pathologists, Registered Nurse, Licensed Practical Nurse, etc.) . Please refer to these acts and regulations if you require further information on these service providers’ requirements.

9(2) Where an operator provides or offers personal choice services, the operator shall

ensure that the personal choice services

a) are offered or provided based on the needs and preferences of the residents,

b) are provided in a space that is appropriate for the purpose, and

c) are provided by a person who holds the required licence or other certification, if

any, for the provision of those personal choice services.



Resident’s Needs and Preferences



Pre-existing personal choice services

continue to be utilized by residents.


representatives regarding the personal

choice services.

Observation of the utilization of the

personal choice services.


schedules, booking information,

appointment books, surveys, resident

meeting minutes or other resident

comments.

Residents’ needs and preferences are

considered when coordinating new



regarding the coordination of personal

choice services.


resumes, care plans, surveys, meeting

minutes or other resident comments.

Personal Choice Service Areas



Space utilized by the personal choice

service is appropriate for the intended

purpose.

Conversations with residents,

employees or service providers

regarding the personal choice areas.

Observation of areas utilized for


Qualifications of Personnel



Personal choice services are provided by a

qualified employee, volunteer or

contractor.


individual is qualified to perform the

service. This information may be found

in trades certificates, diplomas,

registration certificates to a

professional association or letters of

good standing.



Standard 10: Insurance

Intent

To ensure that all long-term care accommodations hold sufficient insurance to mitigate risk

and to ensure the continuation of the accommodation and services to residents.

Note

General liability insurance of at least $2,000,000 per occurrence is required for all

long-term care accommodations. General liability insurance protects the operator’s

business against third party legal liability related to personal injury, bodily harm or

property damage.

Crime insurance is required in all settings in which the operator holds monies or

personal property on behalf of a resident. Crime coverage protects an organization

from financial losses of their own and when they are in custody of other people’s

property. The coverage can be for embezzlement, theft of client’s property or other

financial crimes against the organization.

10(1) Without limiting any other liability to which an operator may be subject, an operator

must insure the long-term care accommodation under a contract of general liability

insurance in accordance with the Insurance Act and in an amount of not less than $2

000 000 per occurrence in respect of the following:

a) bodily harm;

b) personal injury;

c) property damage, including loss of use of the property.

(2) Where an operator operates a long-term care accommodation at more than one

location, the requirements of subsection (1) apply in respect of each location separately.

(3) If an operator holds money or personal property of a resident that has monetary

value, the operator must obtain a comprehensive crime insurance policy in an amount

covering the operator’s potential liability for loss resulting from theft, fraud and other

similar offences, whether committed by employees of the operator or by other persons.

(4) An operator must provide a detailed certificate of insurance to the director annually

and at any other time when requested by the director to do so.

Insurance



Evidence of current insurance for liability

and crime insurance (if applicable) is

provided.

Documentation provided on-site may

include certificates of insurance or

insurance policies.





Standard 11: Contracted Services

Intent

The intent of this standard is to ensure the safety and security of residents by ensuring that

all persons providing additional services under contract are qualified, insured, licensed,

adhere to all relevant legislation and protect the personal information of residents.

Definitions

Services: any accommodation related service occurring on-site, such as personal

choice services, hospitality services, maintenance services, safety and security

services.

Site-specific: a contract for a service at a specific location identified in the contract

by accommodation name or address.

Note

This standard is applicable only to contracts generated by the operator.

11 Where an operator contracts for services to be provided in a long-term care

accommodation, the contract must include, at a minimum,

a) the nature and scope of the service to be provided,

b) who will provide the service,

c) that person’s qualifications to provide the service, if applicable,

d) a requirement that the contractor carry any required insurance, and

e) a provision that addresses the handling of personal information about the

residents of the long-term care accommodation.

Contracts



Where there are site-specific contracts to

deliver services, those contracts include all

points specified in the standard.

Documentation provided may be

current contracts or other service

provider agreements.





Standard 12: Social or Leisure Activities

Intent

To identify expectations regarding the determination, communication and delivery of social

and leisure activities. Social and leisure activities promote healthy lifestyles and residents’

enjoyment of their home and community. Operators who provide social and leisure activities

must ensure that the activities are appropriate and reflect the preferences of the residents by

providing opportunity for residents to give input and feedback. Those persons providing the

social and leisure opportunities must be knowledgeable and qualified to proficiently provide

these services to the population that they are serving.

Definitions

Periodically: the opinions of residents may be solicited on a regular or intermittent

schedule. The special circumstances of the accommodation may require opinions to

be collected regularly (ie. surveys, meetings), when there is a significant change in the

population or needs of the residents, or when there is a change in the capacity of the

accommodation, such as changes in the service level provision or budget.

Appropriate manner: the communication method used in the accommodation

needs to be appropriate to the needs and abilities of the population served. Verbal

communication alone may not be considered sufficient if the resident is able to

benefit from written communication. Likewise, only written communication would

not be effective in a setting in which the residents were unable to read.

12(1) Where an operator provides social or leisure activities for residents, the operator

shall

a) provide activities that address the needs and preferences of the residents,

b) periodically solicit and consider the opinions of residents in planning and

providing social or leisure activities, and

c) respond to resident’s opinions and comments regarding social or leisure

activities.






Social and leisure activities match the

resident needs and preferences (collected

in 12(1)(b)).

Documentation pertaining to 12(1)(b).

and

Documentation of the activities

provided for the residents. This


calendars, posters, care plans, log

books, sign-up sheets or newsletters.

Social and leisure activity programs are

evaluated to ensure that they meet the

needs and preferences of residents.


attendance records, evaluation

programs, meeting minutes, sign-up

sheets or reports.

Individualized social and leisure programs

catered to each resident.


representatives regarding the social

and leisure activities.

Documentation of the social and

leisure activities. This information may

be found in care plans, goal sheets,

schedules, leisure interest forms or

calendars.

Resident Opinion



Meetings are utilized to collect resident

opinions.


regarding their awareness of feedback

methods.


meeting minutes or meeting agendas.

Surveys, feedback cards, or suggestion

boxes are utilized to collect resident

opinions.



methods.

Observation of the availability of

feedback forms (if on an ongoing

basis).


opinions of residents are collected.


completed surveys, result tallies or

completed comment forms.



Response to Resident Opinions



Resident activities are adjusted in

response to the opinions collected.


regarding the changes in social and

leisure activities.


collected resident opinions are utilized.


calendars, posters, notices, care plans

or newsletters.

Residents are informed of the results of

surveys, resident meetings, suggestions,

or other opinions received and the planned

action.


regarding the communication of the

results and/or planned action of the

operator to the feedback received.


results of resident opinions collected

are communicated to residents. This


minutes, newsletters, memos,

announcements or notices.

12(2) An operator shall ensure that information about social or leisure activities is

communicated to residents in an appropriate manner.



Communicating Activities





Residents are notified of the social and

leisure activities through postings.


regarding their awareness of the

communication method chosen by the

operator.

Observation of the postings on

whiteboards, bulletin boards or in

other resident or common areas.

Residents receive copies of activity

schedules or may be able to access the

information on pre-recorded messages or

through other technological media.




operator.

Observation of the communication

material or method.

Documentation demonstrating that all

residents are aware and are able to

utilize the method of communication.


questionnaires, newsletters or

suggestion box responses.

12(3) An operator shall ensure that employees or service providers who are required to

plan, develop, coordinate and deliver social or leisure activities have the

necessary education and knowledge to do so in a way that meets the needs of the

residents.






Job descriptions and qualifications for

social and leisure personnel match the

needs of the residents.


needs of the residents (based on the

job description) and the qualifications

of the social and leisure personnel

match. This information may be found

in job descriptions, certificates,

resumes or other verification of

qualifications.

Contracts with or procurement of service

providers for social and leisure activities.


needs of the residents are met by the

utilization of a contracted service

provider. This information may be

found in contracts, service agreements

or invoices.





Standard 13: Nutritional Requirements

Intent

To verify that menus address the needs of residents, offer quality and respect the input of

residents. Foods are to be safe, palatable, appealing and served in sufficient quantities to

allow residents to receive adequate nutrition and enjoyment from their meals.

Communicating the menus and meal times in a manner appropriate for the residents allows

them to plan their day and have time to communicate any concerns or make any alternate

arrangements that they feel are necessary.

Definitions

Meals, fluids and snacks: includes all foods made available to residents by the

operator and includes choice, substituted items and special diet items (e.g. texture-

modified, diabetic, vegetarian, celiac, low sodium, etc.).

Appropriate manner: the communication method used in the accommodation

needs to be appropriate to the needs and abilities of the population served. Verbal

communication may not be considered sufficient if the resident is able to benefit

from written communication. Likewise, only written communication would not be

sufficient in a setting where the residents were unable to read. Additionally,

depending on the needs of the residents, it may be beneficial for the accommodation

to provide the menus and meal times to residents right before the meal, the same

day, several days in advance or a week in advance.

13(1) An operator of a long-term care accommodation who provides residents with a

meal, fluids and a snack daily shall ensure that

a) the meals, fluids and snacks are

(i) palatable, safe and pleasingly presented, and

(ii) provided in sufficient quantities to ensure adequate hydration and that the

residents’ nutritional needs are met,

and

c) the menu and times at which the meals, fluids and snacks will be served are

communicated to each resident in an appropriate manner.



Quality and Quantity



The majority of residents feel that meals

are nutritious, tasteful, safe, pleasingly

presented and served in sufficient

quantities.

Conversations with residents or

representatives regarding meal

presentation, taste, quantity and

quality.

Observation of meal service.

Where resident conversations are not

possible, the operator can demonstrate

that meals are nutritious, tasteful, safe,

pleasingly presented and served in

sufficient quantities.

Conversation with resident


regarding meal presentation, taste,

quantity and quality.



policies and procedures, surveys,

dietitian assessments, food services

evaluations or food samplings.

Communicating Meals and Times



Residents are notified of meals and meal

times by posted information.



meals, meal times and the


operator.


whiteboards, bulletin boards or in


Residents receive copies of menus and

meal time schedules or they may be able

to access the information on pre-recorded

messages or through other technological

media.


regarding the communication method

chosen by the operator.


material or method.





questionnaires, newsletters,

handbooks, assessments or service

agreements.



Standard 14: Menu Requirements

Intent

To verify that menus which consider residents input offer variety, choice and are provided

on a schedule agreeable to the residents. A menu that incorporates choice, seasonal variety

and residents’ needs and preferences provides residents opportunities to have input and

control over their meals and the feeling of a home-like environment. When substitutions are

made to the menu they must be of similar nutritional value to ensure that the integrity of the

original menu is preserved. Communicating the substitutions made to the residents meals

allows them to plan their day and make any alternate arrangements that they feel necessary.

Meal times are determined in collaboration with or in consideration of the residents to

ensure that meals are served at times suitable to the needs and/or preferences of the

majority of the residents. This provides residents with more opportunity to personalize their

service.

Definitions

Food group: choice and substitutions must be provided within one of the Canada

Food Guide recognized four food groups (Vegetables and Fruit, Grain Products,

Meat and Alternatives, Milk and Alternatives).

Extended meal times: a flexible window of time where meals are available over an

hour or more to allow for residents to choose the meal time that fits into their daily

schedule.

Menu Substitutions: any alteration of the accommodation’s pre-planned menus to

another food item. This does not include individual changes made for a specific

resident preference.



14(1) The operator of a long-term care accommodation shall ensure that the menu

provided for residents

a) offers variety and seasonal variation,

b) provides residents with a choice from within one food group at every meal, and

c) as far as is reasonably practicable, recognizes residents’ food preferences,

religious practices and cultural customs in the planning, preparation and service

of meals.

Menu Variety



One cyclical menu with substitutions made

throughout the year to allow for variety and

seasonal variation.

Documentation of the seasonal

substitutions may be found in

substitution records, or special event

meal records.

Seasonal or a variety of cyclical menus are

used to provide residents with variety and

seasonal variation.

Documentation may be found in

seasonal menu variations (e.g.

Spring/Summer and Fall/Winter).



Menu Choice



The operator provides choice items at the

request of residents. These choice items

are catered to the preferences of the

resident.


regarding their ability to receive a

choice item on request.

Observation of the request for a

choice item.


residents are aware of their ability to

request choice items. This information

may be found in handbooks, menus,

orientation checklists, notice boards or

memos.

The operator provides a choice in one or

more food groups at each meal service as

specified by the menu.



choice available at each meal.



choice is available and communicated

to residents. This information may be

found in handbooks, menu boards or

menus.

The operator provides a selection of choice

items that are always available (e.g. a la

carte menus or other lists of available

items).



choice available at each meal.

Observation of the choices available.


always available choices are

communicated and available to

residents. This information may be

found in handbooks, menus,

orientation checklists, notice boards or

memos.

The operator provides a choice in all food

groups or provides a restaurant style menu

at every meal service.



choice is available and communicated

to residents at each meal. This


handbooks, menu boards or menus.






Residents or their representatives express that meals served meet their food preferences, religious practices and cultural customs.

Conversations with residents or their representatives regarding the meals served.

Meals served match the resident food preferences, religious practices and cultural customs determined at admission.

Conversations with residents or their representatives regarding how the meals served match their food preferences.

Documentation of the resident’s food preferences, religious practices and cultural customs. This information may be found in care plans, goal sheets, likes/dislikes listings or food interest surveys.

Meals served reflect the resident food preferences, religious practices and cultural customs (collected in 14(3)).

Documentation pertaining to 14(3). and

Documentation of the menu items. This information may be found in menus, special event postings or substitution lists.

14(2) Where substitutions must be made respecting items on a menu, those

substitutions must be a) from within the same food groups and provide similar nutritional value as the

original menu items, and b) communicated to the residents.

Menu Substitutions



Menu substitutions are recorded on the

cyclical menu (e.g. Items are crossed out

and the substitution written in so that both

items are legible).


substitutions to the menu are

recorded. This information may be

found on meal planning calendars or

menus.

Menu substitutions are recorded on a

separate document from the menu. The

substitutions reference the date or cyclical

menu date to ensure that substitutions can

be compared to the original item.


substitutions to the menu are

recorded. This information may be

found in communication books, log

sheets, substitutions sheets or special

notices.



Communicating Substitutions



Residents are notified of meals and any

substitutions by posted information.



meals, meal substitutions and the


accommodation.


whiteboards, bulletin boards, or in


Residents receive copies of menus and

meal substitutions or may be able to

access the information on pre-recorded

messages or through other technological

media.




operator.


material or method.





questionnaires, newsletters,

handbooks, assessments or service

agreements.



14(3) An operator shall ensure that residents’ opinions and feedback regarding meals,

fluids and snacks are collected at least yearly and considered in the development

of the menu.

Resident Opinions and Feedback



Meetings are utilized to collect resident

feedback.



methods.


regarding the consideration of resident

feedback.


feedback is collected. This information

may be found in meeting minutes.

and


feedback is considered. This

information may be found in menus,

special event meal records or meeting

minutes.

Surveys, feedback cards, or suggestion

boxes are utilized to collect resident

feedback.



methods.



feedback.

Observation of availability of feedback

forms (if on an ongoing basis).


feedback is collected. This information

may be found in completed surveys,

result tallies or comment forms.

and


collected feedback is considered. This

information may be found in menus,

special event meal records, meeting

minutes or newsletters.



14(4) An operator shall ensure that residents are consulted on a periodic basis

respecting the times of the day at which meals, fluids and snacks are to be

provided or made available to them and shall respond to the residents’ comments

or concerns.

Meal Times



Collaboration with residents on meal times

occurs at resident council meetings,

through surveys or other discussion

methods.


collaboration with residents on the

meal times. This information may be

found in completed surveys, result

summaries or meeting minutes.

Meal service occurs at more than one

seating or through extended meal times

(window of time) for each meal. Snacks

and fluids are readily available for

residents to access.

Conversations with residents regarding

meal, fluid and snack times.

Observation of a meal service.

Documentation demonstrating how

operators make residents aware of the

flexible meal time options. This

information may be found in meal time

postings, orientation checklists or client

handbooks.



Response to Opinions and Feedback



Resident meal, fluid and snack times are

adjusted in response to the feedback

collected.


regarding the changes in meal, fluid

and snack times.


collected feedback is utilized. This


calendars, posters, notices, care

plans, log books, newsletters or

communications with menu provider.

Residents are informed of the results of

surveys, resident meetings, suggestions,

or other feedback received and the

planned action.


regarding the communication of the

results and/or planned action of the

operator to the feedback received.


results of feedback collected is

communicated to residents. This


minutes, newsletters, memos,

announcements, notices or

communications with menu provider.



Standard 15: Cleaning Requirements

Intent

To verify that the long-term care accommodation is cleaned as necessary while respecting

residents’ preferences. Regular cleaning schedules following clear and thorough procedures

support the comfort of residents and maintain a clean living environment and space. To

ensure that residents preferences are met the operator may need to demonstrate how they

have communicated the level of service and when it is provided, altered the schedule to meet

residents’ preferences and that the service does not occur at unreasonable times.

15(1) An operator shall ensure that a clean and comfortable environment is provided for

residents, employees, volunteers, service providers and visitors.

Clean and Comfortable Environment



The accommodation is clean and

comfortable.


representatives, employees,

volunteers, visitors or service

providers on the cleanliness and

comfort of the accommodation.

Observation of a clean and

comfortable environment.



15(2) A long-term care accommodation must be thoroughly cleaned on a regularly

scheduled basis and the level of cleanliness must be maintained as necessary

between regularly scheduled cleanings while respecting the preferences of the

residents as much as possible.

Regularly Scheduled Cleaning



A schedule is provided of the regular

cleaning that is required and clear

responsibility for specific tasks is identified.

Supervisor follow up occurs to ensure the

completion of the scheduled tasks.


representatives regarding completion

of cleaning services.

Observation of the cleanliness of the

accommodation.


cleaning is completed on a regularly

scheduled basis. This information may

be found in job descriptions, duty lists,

special task lists, job routines or

schedules.

A schedule of the regular cleaning that is

required is provided by the operator and

documented verification of work done is

completed.





accommodation.

Documentation may include audits of

work done.

A schedule of the regular cleaning that is

required is provided by the operator and

the monitoring records of what has been

done is completed by the employee

responsible (e.g. sign off).





accommodation.

Documentation may include

checklists, special task lists, duty lists,

schedules, job routines or project work

tracking.



As Needed Cleaning



Written procedures showing that the

operator provides cleaning services on an

as needed basis.

Conversations with residents and their

representatives regarding the as

needed cleaning services.

Observation of ongoing cleaning

services.


operator engages in the as needed

cleaning services. This information

may be found in policies and

procedures, duty lists, cleaning lists,

resident handbooks, service

agreements or log books.

Operator provides cleaning services based

on documented resident need and is in the

resident’s personal space each day to

determine the level of service required.



regarding as needed cleaning

services.

Observation of ongoing cleaning

services.

Documentation of the needs of the

residents for cleaning services. This

information may be found in care

plans, duty lists, logs or job

descriptions.

Resident Preferences



The operator communicates the cleaning

schedules to residents and considers

resident preferences in adjusting the

schedules where needed.


regarding the suitability of cleaning

schedules.



preferences in the cleaning schedule.


cleaning schedules are communicated

to residents and their preferences are

considered. This information may be

found in welcome cards, orientation

materials, surveys, meeting minutes,

handbooks or service agreements.



15(3) Written cleaning procedures must be established and followed at all times to

ensure a clean living environment.

Cleaning Procedures



Written information on how cleaning is to

be performed.

Observation of implementation of the

cleaning procedures.


cleaning procedures. This information

may be found in policies, procedures,

duty sheets, checklists or job

descriptions.

Training on how cleaning is to be

proficiently performed is provided to

employees.




information on the cleaning

procedures is provided to employees.


training manuals, orientation

checklists, shadowing checklists or

training records.

A contractor or external service provider

provides cleaning services and written

information on how cleaning is performed.




cleaning procedures. This information

may be found in the signed contract

between operator and contractor,

policies, procedures, duty sheets,

checklists or job descriptions.



15(4) Appropriate mechanisms must be used to minimize unpleasant odors in the long-

term care accommodation.

Odour Control



Odours are not present. Conversations with residents, their


regarding the presence or absence of

odours.

Observation noting the absence of

odours.

The operator engages in odour elimination

or minimization to the extent required to

provide a comfortable and clean living

environment for residents.

Observation of techniques used to

eliminate or minimize unpleasant

odours. This may be accomplished by

the use of garbage or laundry lids, the

use of fans or deodorizers, frequent

garbage and soiled laundry removal,

adequate smoke room ventilation,

and/or appropriate cleaning of pet

areas.





Standard 16: Continuation of Services

Intent

To verify that there is a plan for the ongoing provision of accommodation services should

there be an unexpected emergency. Advanced preparation is the key to mitigating the impact

of unexpected events or emergencies leading to the disruption of regular service delivery.

Many long-term care residents struggle with limited personal mobility, cognitive impairment

and other physical challenges that render them even more vulnerable during emergency

situations. With adequate knowledge and planning, the harmful effects of such unanticipated

events can be minimized. Contingency plans must be developed with deliberate

consideration of the very unique needs of the resident population and reviewed on an annual

basis to ensure that they remain current.

Definitions

Employment disputes: unplanned for deviations from normally scheduled staffing

presence or any other activity/event that may result in staff shortage that disrupts the

ability of the accommodation to provide services to the residents.

Essential equipment: equipment that is vital to the operation of the

accommodation that without would require additional actions to be taken to

maintain services for the residents. Equipment may include boiler, furnace, hot water

tank, elevator, generator, communication equipment, security equipment, emergency

call systems, sanitation equipment, food preparation equipment, food storage

equipment, food service equipment, laundry or cleaning equipment.

Excessive heat: temperatures at a level that pose a safety risk to residents or may

result in a temperature advisory from Environment Canada.

Extreme weather: instances of thunderstorms, hailstorms, tornadoes, heavy

precipitation, blizzards, snowstorms, ice storms, dust storms, heat waves or cold

waves that may impact an operator’s ability to provide services.

Necessary accommodation services: the services deemed necessary by the

operator to be continued in an emergency, but must include meeting residents’ basic

needs.

Other disruptions: may include excessive heat, reduced heat, fire, floods, sewer

back ups, evacuation, unscheduled absence of the operator (illness, accident, etc) or a

disruption in accommodation related services (safety and security, meals, cleaning,

laundry, maintenance and building).

Other utilities: includes water, gas and telephone service.



Sheltering in place: a situation in which a judgment has been made based on the

safety and comfort of residents, to keep residents within the accommodation rather

than evacuate. Accommodation services continue to be provided within the

accommodation at an essential level.

16(1) An operator shall develop, maintain and implement as necessary contingency

plans to provide for the continuation of necessary services to residents in the

event of the failure of electrical power, or other utilities, the breakdown of essential

equipment, extreme weather conditions, employment disputes, and other

disruptions.

Contingency Plans



The contingency plan is site specific and ensures

the continuation of necessary accommodation

services whether evacuating or sheltering in

place. Consideration is given to the type of

disruption that may lead to an activation of a

contingency plan and the appropriate responses

that may be needed depending on the situation.

At a minimum contingency plans must address:

Failure of electrical power

Failure of other utilities (i.e. water and gas)

A plan for the breakdown of essential

equipment in the accommodation

Extreme weather conditions that may

reasonably occur in the area of the

accommodation

Staff shortages and/or employment disputes

Evacuation and relocation

Disruptions to safety and security services

Disruptions to meal services

Accommodations may also have contingency

plan(s) in place for the following, where the

occurrence of the event disrupts necessary

services for the residents:

Disruption of telecommunications / IT systems

Flood / sewer back up

Excessive or reduced heat

Disruption of cleaning, laundry or maintenance

services

Documentation of the

contingency plan. Information

may be found in manuals,

policies and procedures,

department specific plans or

training guides.

Where additional information is

required to develop a contingency

plan see the resource section 10

for planning websites and Appendix

A ‘Accommodation Standard 16:

Points to Consider when

Developing Plans’.



16(2) A contingency plan must

a) mitigate the impact of the disruption on the residents,

b) be communicated and made available to residents and their representatives,

visitors, volunteers, employees and service providers,

c) be practicable in the circumstances in which it is intended to be used,

and

d) be reviewed on an annual basis to ensure that it remains effective.

Mitigation of Impact and Practicability

The focus of the contingency plan is to ensure that residents are safe and comfortable

and that the disruption to their services is kept to a minimum.

The contingency plan needs to be practicable in both situations of evacuation and

sheltering in place. Consideration needs to be made as to how residents will be kept

safe and comfortable and that services continue to be provided whether they are in the

accommodation itself, being transported to another site, or at singular or multiple

evacuation sites.

Contingency plans should be sufficiently detailed so that they are feasible and context

specific given the size and nature of the accommodation and the resident population that

it serves. Plans that exist in the format of blank templates, resource print outs, or lists of

contact phone numbers will not be sufficient for compliance.



Communicating the Plan



Information on the contingency plan, in

whole or part, is posted in the

accommodation. If the entire plan is not

posted, employees need to know where to

access the whole plan and are able to

direct others to the whole plan on request.


representatives, employees,

volunteers and service providers

regarding their awareness of the plan

locations.

Observation of information on the

contingency plan posted in the

accommodation.

Observation of the postings detailing

the location of the contingency plan.


employees, residents, representatives,

volunteers and service providers are

notified of the location of the

contingency plan. This information

may be found in handbooks,

orientation materials, or service

agreements.

Information on the contingency plan is

provided to residents, their

representatives, employees, volunteers

and service providers through training or

other verbal methods.


representatives, or employees

regarding information provided on the

contingency plan.


operators provide training to

employees, residents, representatives,

volunteers and service providers. This


minutes, training documentation, or

certificates.

Information on the contingency plan is

provided to residents, their

representatives, employees, volunteers,

visitors and service providers in a written

format.


representatives, or employees

regarding information provided on the

contingency plan.


operators provide information to

employees, residents, volunteers,

service providers. This information

may be found in handbooks,

orientation manuals or checklists,

newsletters or emergency manuals.



Annual Review



The contingency plan is reviewed through

a meeting discussion format (staff

meetings, board meetings, resident and

family meetings).


contingency plan was reviewed

annually. Information may be found in

meeting minutes.

The contingency plan is reviewed through

an administrative/committee review

process.


contingency plan was reviewed

annually. Information may be found in

meeting minutes, a review date on the

plans, a letter of review, or a dated

footnote on the plans.

Ensure that any changes made to the contingency plan are communicated to residents,

their representatives, employees, volunteers, visitors and service providers. See

16(2)(b).





Standard 17: Prevention of Abuse

Intent

To verify mechanisms are in place for the prevention, identification and reporting of abuse.

Operators of long-term care accommodations are responsible for ensuring that all employees

receive appropriate education respecting the identification, prevention and reporting of

suspected abuse. Operators are also responsible for ensuring that residents, their

representatives, volunteers and service providers are aware of the contacts and resources

available to them should they have any concerns or complaints regarding abuse.

17(1) An operator shall develop and maintain written processes that

a) promote the prevention of abuse of the residents of the long-term care

accommodation,

and

b) provide information respecting the reporting of suspected abuse to the proper

authorities.

Written Processes



The operator has a written process on the

prevention of abuse and the reporting of

suspected abuse.


policies and procedures, guidelines,

training materials, handbooks or

pamphlets.

17(2) An operator shall ensure that all employees receive appropriate education

respecting the identification, and reporting of suspected abuse and the prevention

of abuse of residents.

Training



The operator provides training on the

identification, reporting and prevention of

abuse to all employees.


orientation materials, training manuals,

training records, attendance records or

certificates.



17(3) An operator shall ensure that information respecting the identification and reporting

of suspected abuse and the prevention of abuse of residents is provided to

residents, their representatives, volunteers and service providers.

Information Provision



Postings on the identification, reporting

and prevention of abuse is available in a

common area of the accommodation.



information.

Observation of postings.

The operator provides written pamphlets,

brochures or other media on the


abuse.


representatives, volunteers or service

providers regarding the information

provided to them.


handbooks, orientation materials,

pamphlets, brochures, policies or

guidelines.

The operator provides training on the


abuse.


representatives, volunteers or service

providers regarding the information

provided to them.


orientation materials, training

materials, meeting minutes, training

records or information session

attendance records.



Standard 18: Resident Safety and Security

Intent

To verify that mechanisms are in place to support resident safety and security on a round-

the-clock basis. It is important that long-term care residents feel secure and safe in their

living environment and surroundings. Operators can ensure this by having appropriate

monitoring mechanisms, accounting mechanisms, security systems, emergency call systems

or communication systems in place. Where mechanical or electronic systems are in place

they need to be inspected regularly to ensure that they are in good working order and those

that utilize them need to be educated in their use. Where an incident of a critical nature

occurs in an accommodation, the Director of the Compliance and Monitoring Branch is

notified so that resident safety and security is not further compromised.

Definitions

Security systems: a system that warns the operator of an intruder or other breach.

This may include security systems or other intruder alert systems.

Communication systems: a system that the resident may use to access assistance

from an employee. This may include nurse call, pendants, emergency call bells or pull

cords.

Emergency call systems: a system that lets an employee know that the resident is

in an emergency situation. This may be wanderguards, door alarms, bed alarms or

wheelchair alarms.

Incident: an event related to the Accommodation Standards that has occurred; causing death or serious harm to a resident, a resident unaccounted for, an unplanned for activation of a contingency plan or extensive damage to the accommodation.

o Serious harm: Physical or psychological injury which is life threatening and/or traumatic to the individual.

o Extensive damage: damage to the extent that the ability of the operator to continue to provide accommodation services and a safe and secure environment is affected.

Director: the Director of the Continuing Care Standards and Licensing Unit, Alberta Health.

Monitoring Mechanism: equipment or processes used to ensure that residents are

safe in addition to the personnel on site. These may include security systems,

emergency call systems, communication systems or surveillance systems.



Note

Where manufacturer’s recommendations are not available or do not state inspection

recommendations for security, emergency call and communication system the

operator may set out a schedule of regular inspections and testing of the system(s)

that is deemed to be reasonable in relation to the safety of the residents.

18(1) An operator shall develop and maintain written processes that promote the safety

and security of residents, including processes that

a) account for all residents on a daily basis,

and

b) ensure that monitoring mechanisms and personnel are in place on a round-the-

clock basis.

Accounting for Residents



The number of staff and residents is such that staff are aware of residents at all times.

Documentation provided may include staffing schedules, job duties and care plans.

Residents are accounted for during daily routine activities such as meals or medication times.

Observation of assigned seating at meals allowing for accounting of residents.

Documentation provided may include MAR sheets, meal attendance sheets or handbook information.

Residents are accounted for using formalized tracking tools such as sign in/out books or census documents.

Documentation provided may include sign in/sign out books, daily census recordings or bed checks.

Monitoring of Residents



The accommodation is staffed 24 hours

per day, seven days per week and

monitoring systems are in place.

Observation of monitoring systems.


staffing schedules or care plans.

18(2) Where a long-term care accommodation has a security system, the security

system must be maintained, inspected, and tested as recommended by the manufacturer of the security system.



Security Systems



The security system is regularly inspected,

tested and maintained by an employee or

outside contractor.


manufacturer recommendations. This

information may be found in manuals,

guidelines or letters.

and


recommendations are followed. This

information may be found in log

sheets, invoices, maintenance

requisitions, or other preventative

maintenance records.

Computerized monitoring of all security

systems is in place that has the capacity to

report on all failures in the system. The

computerized system is inspected, tested

and maintained to ensure that it is in

working order.

Observation of the computerized

system.


computerized system is able to alarm

for all system failures and the system

is in working order. This information

may be found in manuals, incident

reports, system descriptions or system

logs.

The security system is checked daily by a

designated employee as part of a regular

routine and a process exists for reporting

deficiencies to ensure the system is

maintained in good working order.


task is designated to a specific

employee. This information may be

found in job descriptions, duty lists or

routines.

and


there is a procedure for the checks

and the reporting of deficiencies. This

information may be found in policies

and procedures, maintenance

requisitions, job duties or other

guidelines.



18(3) Where a long-term care accommodation has a communication system or an

emergency call system, the system must be one that is appropriate to the type of

building in which it is located and suitable for the needs of the residents and must

be maintained, inspected and tested as recommended by the manufacturer of the

system.

Suitability



The communication or emergency call

system is appropriately matched to the

type of building and the needs of the

residents.

Conversation with the operator

regarding the suitability of the system

in use.

Observation of the building and the

systems in use.


communication or emergency call

system is suitable. This information

may be found in care plans,

assessments, incident reports,

managed risk agreements, residential

service agreements or policies and

procedures.

Where the communication or emergency

call system is not fully suitable for the

residents or the building the

accommodation has additional practices in

place to make up for the deficiency.


additional practices are in use to

ensure the safety of all residents. This

information may be found in policies

and procedures, job duties, guidelines,

job descriptions, log books or care

plans.



Maintenance



The communication and emergency call system is regularly inspected, tested and maintained by an employee or outside contractor.

Documentation demonstrating the manufacturer recommendations. This information may be found in manuals, guidelines or letters. and

Documentation demonstrating that the communication or emergency call system is regularly inspected, tested and maintained. This information may be found in log sheets, invoices, maintenance requisitions, or other preventative maintenance records.

Computerized monitoring of all communication and emergency call systems is in place that has the capacity to report on all failures in the system. The computerized system is inspected, tested and maintained to ensure that it is in working order.

Observation of computerized system. Documentation demonstrating that the

computerized system is able to alarm for all system failures and is in good working order. This information may be found in manuals, system descriptions, incident reports and system logs.

The communication and emergency call system is checked daily by a designated employee as part of a regular routine and a process exists for reporting deficiencies to ensure the system is maintained in good working order.

Documentation demonstrating that the task is designated to a specific employee. This information may be found in job descriptions, duty lists or routines.

and Documentation demonstrating that

there is a procedure for the checks and the reporting of deficiencies. This information may be found in policies and procedures, maintenance requisitions, job duties, or other guidelines.



18(4) Any incident within the long-term care accommodation or its grounds in which the safety or security of a resident is breached must be documented and reported to the director along with the actions taken to address the incident or remedy the breach, as the case may be.

Reporting to the Director

Reportable incident are to be submitted to the Director within two business days of the

incident occurring by the operator.

Reportable

Incidents:

An event related to the Accommodation Standards that has

occurred:

□ Causing death or serious harm to a resident,

□ A resident unaccounted for,

□ An unplanned for activation of a contingency plan, or

□ Extensive damage to the accommodation.

Reportable

Incident Form:

The reportable incident form can be found on-line at:

http://www.health.alberta.ca/services/continuing-care-

forms.html.

Check ‘Health Funded’ when opening the form to populate

the appropriate sections.

Forms may be submitted electronically using the on-line

form, by e-mail to [email protected] and

[email protected]

Please ensure that additional notifications are completed as

per existing zone processes.

Help with

determining what

to report

A decision guide and examples are provided to assist operators in

determining what incidents meet the reportable incident criteria

(Section 7 or on-line at:

http://www.health.alberta.ca/documents/CC-Reportable-Incidents-

Decision-Process.pdf)

Continuing Care

Health Service

Standards

There is also a requirement to report incidents under the Continuing

Care Health Service Standards. The reportable incident form,

decision guide, examples, and process can also be utilized in

reporting incidents under these standards.





http://www.health.alberta.ca/documents/CC-Reportable-Incidents-Decision-Process.pdf




18(5) An operator shall ensure that all employees and, where appropriate, residents, service providers and volunteers receive adequate training respecting any security, communication or emergency call system in use in the long-term care accommodation.

Training



The operator provides training to those

persons utilizing the security,

communication, or emergency call

systems.


employees, volunteers and service

providers regarding their awareness of

the usage of the system.



training manuals or training records.





Standard 19: Trust Accounts

Intent

To verify there are mechanisms in place to safeguard any funds entrusted to the operator by the resident. To ensure that resident have access to funds held in trust.

Definitions

Trust accounts: any account (group or individualized) or internal holding system (cash box or safe) where funds held on behalf of the residents are kept. This includes situations where the operator receives regular monthly deposits from the resident/responsible person at the first of each month and the resident withdraws the funds during the course of the month. Situations where no money is held and the residents are billed back for services are not considered to be a trust account.

Receipt: an individual receipt or accounting of an expenditure. The receipt may be an accounting of the expenditures after a certain point of time (ie. Monthly) or at the time of each expenditure.

Note

Where an operator provides funds or statements to residents/representatives on an ‘upon request’ basis, a reasonable length of time for fulfilling the request is within two business days for day to day transactions and within 60 calendar days for a closure of a trust account.

19(1) Where an operator holds funds on behalf of a resident for a period longer than 31

days, the operator shall

a) deposit those funds into a trust account opened and maintained for that

purpose,

and

b) provide a receipt for each transaction.



Opening and Operating Trust Accounts



The operator demonstrates the trust

account system that is in place.

Conversations with employees,

residents or their representatives

regarding the trust accounts.


bank statements, transaction receipts,

ledger books or orientation materials.

The operator has a written process on how

trust accounts are opened and maintained.

Conversations with employees,

residents or their representatives

regarding the trust accounts.


policies and procedures, written

guidelines, transaction receipts, trust

account agreements, handbooks, or

orientation materials.

19(2) An operator shall ensure that easily understandable records are maintained in

respect of the trust account showing opening and closing balances and make

those records available for inspection by residents or their representatives free of

charge.

Trust Account Records



The operator provides a regular or periodic

trust account statement free of charge.

Conversations with residents/


issuance of trust account statements.


statements, letters or statement issue

schedules.

The operator provides trust account

statements upon request free of charge.

Conversations with residents/

representatives regarding their

awareness of how to receive a trust

account statement.


residents are notified of how they may

request trust account statements. This


handbooks, terms of occupancy,

admission agreements, trust account

agreements, training materials or

orientation materials.



19(3) An operator shall return funds held in trust to the resident or the resident’s

representative on receiving a request in writing to do so.

Withdrawal of Funds



The operator demonstrates how the

process for withdrawing funds from trust

accounts works.


letters, emails, memos, receipts,

request forms, withdrawal forms or

other withdrawal documentation.

The operator has written processes

dealing with the withdrawal of funds from

trust accounts.



trust account agreements, service

agreements, handbooks or orientation

materials.





Standard 20: Corporate Status

Intent

To verify that the long-term care operator maintains the incorporated body in good standing. 20 The organization is an incorporated body in good standing to do business in the

Province of Alberta and the respective municipality, if applicable.

Corporate Status



The name of the incorporated body is

provided to the Compliance and Monitoring

Branch for a corporate registry search.


incorporation documents of the body.

Corporate registry documentation is

provided showing the incorporated body to

be active.


statements or annual returns.





Standard 21: Water Temperature

Intent

To ensure the safety of residents by preventing scalding and other injuries associated with

extreme water temperatures.

Definitions

Sufficiently knowledgeable employee or service provider: has an understanding

of the tub operations and controls and is aware of the accommodation’s process for

taking and recording temperatures.

Therapeutic tub: a tub in which a resident is lifted into it or it is fully accessible,

often by a side door, which may or may not include a reservoir for water, jets,

hydromassage or hydrosound. The resident is assisted to bathe in a therapeutic tub

and the water temperature is regulated by the tub and/or the care provider. This is

not a residential type tub. Examples of this are: Arjo, century, parker, rhapsody,

freedom, advantage, serenity, bellentra or primo tub.

Flowing water: the maximum hot water visually seen flowing from the faucet. An

external temperature gauge is necessary to measure the temperature of this water.

Maximum safe level for water temperature as defined by the Alberta Building

Code:

o “If the authority having jurisdiction deems it necessary to protect children,

the elderly, or persons with disabilities or infirmities from burns, … b) the

temperature of the water from faucets shall be limited to a maximum of

49○C.” (2014, 7.1.2.2)

Maximum safe level for water temperature as defined by the National

Plumbing Code:

o “3) All mixing valves supplying shower heads shall be of the pressure-

balanced, thermostatic, or combination pressure-balanced/thermostatic type

capable of a) maintaining a water outlet temperature that does not exceed

49°C and b)limiting thermal shock.” (2010, 2.2.10.7)

o “4) The temperature of water discharging into a bathtub shall not exceed

49°C.” (2010, 2.2.10.7)



Note

Requirements for water temperature testing vary based on the accommodation’s

unique water system. See Section 10: Resources Appendix B for additional examples

and information.

Resident education may not be applicable in some accommodations where residents

are independent or have been assessed as capable of ensuring safe water

temperatures or where personnel assist residents in all areas related to water usage.

For therapeutic tubs, the temperature of hottest water flowing into each tub, not the bath water temperature that an individual will be bathed in, must be taken prior to the first bath of the day and documented.

21(1) An operator shall ensure that the temperature of flowing water provided for

personal use in areas used by the residents does not exceed the maximum safe

level established in the Alberta Building Code.

Safe Water Temperatures



Regularly scheduled checks of the hot

water temperature flowing out of the taps

in resident areas to ensure that it does not

exceed the predetermined safe level.


safe water temperatures are

maintained in resident areas. This

information may be found in logs,

checklists or calendars.

21(2) An operator shall ensure that safe water temperature for the personal use of

residents are maintained through

a) employee and resident training and education

b) proper maintenance and monitoring of equipment,

and

c) appropriate risk mitigation procedures.

Education (Residents)



Information provided to residents on safe

water temperatures.


regarding their understanding of safe

water temperatures.

Documentation of education received

by residents. This information may be

found in orientation materials, meeting

minutes, move-in checklists, or

posters.



Training (Employee)



The operator provides training on appropriate temperatures and process for reporting undesirable water temperatures.

Conversations with employees regarding safe water temperatures.

Documentation of training received by employees. This information may be found in training records, orientation forms, meeting minutes, move-in checklists, or posters.

The operator provides training on measuring hot water temperatures.

Conversations with employees regarding their understanding of safe water temperatures.

Documentation of training received by employees. This information may be found in training records, training materials, orientation forms and meeting minutes, or posters.

Maintenance and Monitoring of Equipment



Corrective maintenance records for the hot

water heating system and therapeutic tubs.


hot water heating equipment is

repaired and maintained. This

information may be found in work

orders, requisitions, invoices or logs.

Preventative maintenance records for the

hot water heating system and therapeutic

tubs.


hot water heating equipment is

regularly inspected and maintained.


preventative maintenance records,

logs, invoices, contracts or checklists.



Risk Mitigation Procedures



Limiting resident access to high water

temperature areas (ie. Laundry and

kitchen).

Observation of limitations to resident

access. This may be found as locked

doors, signage, etc.


certain areas are not for resident use.


policies and procedures, resident

handbooks, or orientation information.

The installation and maintenance of mixing

valves, scald free taps or automatic shut-

off systems.


regarding the system installed.

Observation of mixing valves and

temperature gauges.


there is a preventative maintenance

plan for mixing valves, scald free taps

or automatic shut off systems. This


preventative maintenance documents,

logs or checklists.

21(3) An operator shall ensure that all maintenance personnel and employees involved

with the water system are sufficiently knowledgeable in the function and proper operation of the water gauges, water mixing valves and therapeutic tub controls, if any, to maintain safe water temperatures.




Job descriptions and qualifications for

maintenance personnel match the needs

of the water system (ie. Power engineers

(Class 1-5) certificate of competency,

special boiler operator certificate of

competency).


needs of the building (based on the

job description) and the qualifications

of maintenance personnel match. This

information may be found in job

descriptions, certificates, resumes or

other verification of qualifications.

Contracts with or procurement of qualified

persons for maintenance to the water

system (Arjo, plumbers, etc).


needs of the water system are met

with the periodic procurement of an

appropriate water system technician.


contracts or invoices.



21(4) Where a long-term care accommodation has one or more therapeutic tubs, the operator of the long-term care accommodation shall ensure that a sufficiently knowledgeable employee or service provider tests the temperature of the hot water flowing into each therapeutic tub each day prior to the first bath of the day and documents the temperature in a logbook or on a log sheet kept in the tub room for that purpose.

Therapeutic Tub



The temperature of the hot water flowing

into the therapeutic tub is taken and

recorded prior to the first bath of the day.

The record of water temperatures is kept in

the tub room.

Observation of the water temperature

logs kept in the tub room.

Documentation provided may be a log

books or log sheets.

Where a therapeutic tub has an automatic

shut-off when the tub exceeds a preset

temperature, and there is insufficient time

to get an external temperature reading the

digital temperature read out can be used

as the temperature recording.

Observation of the water temperature

logs kept in the tub room.

Documentation provided may be a log

books or log sheets.





Standard 22: General Information

Intent

This standard is intended to ensure that residents are assisted in locating resources that they

are interested in or in need of so that they can make informed decisions. Having access to

general information can assist residents to develop meaningful ties within their communities

and to improve their access to available resources.

Definitions

General information: resources can take the form of pamphlets, booklets,

handouts, contact names and phone numbers or links of information that is relevant

to the resident. It is not necessary for an operator to have all information, but to

have some relevant information and to be able to link the resident with other

contacts should additional or different information be needed.

22 An operator shall make available as necessary to residents and their representatives

current general information respecting relevant community, municipal, provincial, and

federal programs.

General Information Provision



The operator provides a resource area to

display relevant information for residents.


regarding their access to resources.

Observation of the resource area.

The operator provides resources to

residents in written format.




admission packages, handbooks or

newsletter.

The operator provides access to

community resources via various media

outlets.



Observation of media / equipment.


residents are able to access and

utilize the media provided. This

information may be found in care

plans, assessments, meeting minutes,

or surveys.



General Information Provision (Continued)



The operator employs a social worker or

other employee for the purpose of

providing resources to residents.

Conversations with

residents/representatives regarding

their access to resources.


job descriptions, job duties, or

handbooks.



Standard 23: Information Respecting the Long-term Care Accommodation

Intent

Information regarding the long-term care accommodation needs to be transparent and

accessible to applicants, residents and their representatives. This standard is intended to

ensure that prospective and current residents and their representatives are made aware of all

relevant information to assist them to make decisions on their accommodation and

accommodation related services. The degree of information provided to applicants may vary

depending on the information that they have requested. It is, however, necessary that

operators make available all applicable information for residents or their representatives.

Definitions

Move in and orientation: the process for move in and the expected orientation

items to familiarize the resident with the accommodation and the services provided.

Monthly basic accommodation charges: information on the charges for the

accommodation and what is covered by this charge.

Information concerning maintenance and cleaning schedules: information on

the frequency of cleaning, hours of service in which service is provided, project work

scheduling, repair and replacement schedules and how to report concerns to

maintenance.

List of optional services and charges: information on any additional services (e.g.

cleaning, laundry, hairdressing, personal choice services, cable, etc) offered by the

operator in the accommodation for a fee above and beyond that which is included in

the residential services agreement and what the fee is for the service.

Notice periods for rate increases: information of the notice period for rate

increases stated in days or months or on a specific date (ie. January 1 of each year)

for the accommodation and/or accommodation services.

o Note: Rates for Long-term Care are set by the Ministry of Health. This

notice period refers to the amount of notice the accommodation

commits to provide residents/representatives prior to the

implementation of any Ministry approved increases.

Notice periods for termination of services or tenancy: information of the notice

periods for services or tenancy to be terminated by the operator or the resident or

their representative. The notice period may apply to situations of discharge, transfers

or other endings of services at a specific accommodation.



Required inspections: Inspections completed by jurisdictions responsible for

Accommodation Standards, Environmental Health or the Safety Code, such as

Building and Fire.

Concerns and complaint resolution process: forms or information pertaining to

how residents can express complaints and concerns and the steps that will be taken

to resolve the issue.

23(1) An operator shall provide on request to applicants, residents and their

representatives current information and, where necessary, forms respecting the

operation of the long-term care accommodation, including

a) the process of moving in and orientation,

b) basic accommodation and service charges on a monthly basis,

c) available optional personal services and their charges,

d) cleaning and maintenance schedules,

e) the notice period applicable to rate increases,

f) the house rules of the long-term care accommodation and circumstances that

could lead to the termination of residency,

g) information respecting the measures taken by the operator to protect the

privacy and personal information of residents,

h) information respecting trust accounts, if applicable

i) information respecting the results of required inspections of the long-term care

accommodation,

and

j) the written process for resolving concerns or complaints.

Accommodation Information Provision



The operator provides information to

residents/representatives verbally following

an orientation checklist.


orientation materials or checklists.

The operator provides information to

residents/representatives in a written

format.


intake packages, application forms,

resident agreements, handbooks,

welcome packages, policies or

pamphlets.



Accommodation Information Provision (Continued)



The operator communicates to

residents/representatives the availability of

information that it has in written format.


residents are notified of the availability

of information. Documentation

provided may include orientation

materials, orientation checklists, or

postings.

and


operators policies and processes.


policies, procedures, memorandums,

or other documents.

23(2) An operator shall ensure that a residential services agreement is signed by each

resident or the resident’s representative and by an authorized representative of

the long-term care accommodation.

Residential Service Agreement



The operator provides a signed residential

services agreement.


one or more signed service

agreements.

23(3) A residential services agreement

a) may be a separate document on its own or may form part of another document,

and

b) must clearly state

i) the residential services provided,

ii) the rates charged for those services, and

iii) the notice periods that apply to rate increases and the termination of

services or residency.



Terms of the Agreement





The operator utilizes one residential

service agreement covering all points.



The operator utilizes multiple agreements

covering all points.



The operator utilizes an agreement in

conjunction with signed addendums which

may cover some points.


residential service agreements and

addendums.


________________________________________________________________________________________________ © 2010-2015 Government of Alberta Standard 24 1

Standard 24: Concerns and Complaints

Intent

Operators must have a process in place for dispute resolution. Having a process and communicating it with residents and their representatives allows them to have any concerns and complaints addressed quickly.

Definition

Concerns and complaints: issues expressed to the operator by the resident, their representative or others concerning the accommodation, the building that houses it, the grounds or the accommodation services provided or arranged for by the operator.

24 An operator shall develop and maintain a written process for the resolution of

concerns and complaints about the long-term care accommodation and the services

provided and shall document every concern or complaint received and the measures

taken to resolve it.

Written Process



The operator has written processes on the

resolution of concerns and complaints.


policies and procedures, flowcharts,

forms with instructions for use,

handbooks, welcome packages,

guidelines, posters or pamphlets.

Documentation of Concerns and Complaints



The operator retains the concern or

complaint and provides evidence of the

action taken to rectify the situation.


action was taken to rectify the

complaint. This information may

include requisitions, receipts, referrals,

assessments or policies and

procedures.

The operator logs the complaints and

concerns and the action taken.


log books or communication books.

The operator utilizes meetings to resolve

and document complaints.


meeting minutes or agendas.

The operator utilizes complaint forms or

correspondence with the complainant to

document action taken.


forms, letters or emails.





Standard 25: Certificate Posted

Intent

To ensure that residents and their representatives are aware of the status of the long-term

care accommodations certification.

25(1) An operator shall post the certificate of compliance to the long-term care

accommodation standards issued to the operator, in a prominent place in the long-

term care accommodation to which it pertains.

Posted Certificate



The posted certificate is visible in the

accommodation.

Observation of the posted certificate.





Standard 26: Criminal Record Checks

Intent

The intent of this standard is to ensure that all new volunteers, service providers and

operators providing direct services to resident undergo a criminal records check to support

the safety and security of residents.

Definitions

New: any employee, volunteer, or service provider that commenced after March 31,

2007.

Volunteer: any volunteer that provides direct services to the resident.

Service Provider: any accommodation or personal choice service provider that is

not employed by the accommodation that has independent (unaccompanied by staff)

access to residents.

Note

□ For those employees, volunteers and service providers under the age of 18 where a

criminal record check cannot be completed, it is recommended that they do not have

independent direct access to residents (ie. One on one in resident rooms).

□ Criminal record checks are considered to be one way of screening applicants, but

should not to be considered the sole determination of an applicant’s suitability.

□ The content of a criminal record check may vary among communities and police

departments. Operators may want to contact their local police department to

determine the extent of the information provided.

□ Vulnerable Sector Searches may be a part of a Criminal Record Check. The

determination to complete a vulnerable sector search is a risk management decision

for the operator to make based on the resident population they are serving and the

position being hired to.

26 An operator shall ensure that each new employee, each new volunteer, and each

new service provider whose duties involve the provision of services directly to

residents must provide a criminal record check.



Criminal Record Checks





Criminal record checks for employees,

volunteers and service providers are kept

on file.


criminal record checks.

Criminal record checks for external service

providers (e.g. housekeeping, food

services, etc.)


current contracts or other service

provider agreements.

Verification records that a criminal record

check was viewed and deemed to be

satisfactory are completed.


checklists, records, application forms,

or commencement forms.

Criminal record checks for foreign workers

are kept on file.


criminal record checks, or work

permits from Canada Immigration.



Standard 27: Privacy and Personal Information

Intent

To ensure that operators maintain the privacy and security of residents’ personal

information, using it only as required in the delivery of services. Written policies and

processes regarding the collection, use or disclosure of the personal information of residents

must comply with applicable privacy laws. Any personal information related to residents

should only be accessible to the staff members who interact with those residents and not be

accessible to other residents, contractors, visitors and staff members who do not work

directly with residents or who do not “need to know”, or have access to, that personal

information.

Definition

Personal information: information about an identifiable individual. This

information may be in written, photographic, verbal or electronic form.

27(1) An operator shall ensure that the privacy and the personal information of residents

is protected.

Protection of Information and Privacy



Personal information of residents is

protected regardless of format (digital/

electronic or paper) or location (on site, off

site, or during transportation).

Observation of protection of personal

information.


internal or external privacy audits,

consent forms and assessments as

appropriate.



27(2) An operator shall develop and maintain written policies respecting the protection

of residents’ privacy and personal information and shall

a) train employees and volunteers in implementing the policies,

and

b) ensure that residents and their representatives are informed respecting the

policies.

Written Processes



The operator has written policies,

procedures and processes regarding the

collection, use and disclosure of resident

personal information and how it ensures

resident’s privacy.


policies, procedures, guidelines and

brochures.

The operator has written processes in

place to ensure residents understand their

rights to access to their own personal

information that the accommodation may

have about them.


policies, procedures, guidelines and

brochures.

Training



The operator provides training and written

information (copies of policies and

procedures) to contractors, volunteers and

staff regarding the collection, use and

disclosure of personal information.

Conversations with contractors,

volunteers or staff regarding the

protection of personal information.

Documentation may include


training materials, checklists, forms,

sign in sheets, or contracts with

privacy protection clauses in them.



Information on Processes



The operator notified

residents/representatives verbally and

documents that the discussion has

occurred.



awareness of the operator’s policies in

the protection of personal information.


meeting minutes, or orientation

checklists.

The operator provides training to

residents/representatives in how the

operator protects their personal

information.






training materials, orientation

materials, sign-in sheets or training

records.

The operator provides written information

to the residents/representatives on the

protection of their personal information.






policies and procedures, consent

forms, handbooks or admission

agreements.





Standard 28: Safety and Security

Intent

Staff must be aware of the expectations of their employment. This standard is intended to

ensure that employees have access and are aware of the policies and procedures that protect

resident safety.

Definition

Policies and procedures: any written document approved for implementation for

the safety of residents on the accommodation or an accommodation related service

(e.g. incident reporting, security systems, communication systems, emergency call

systems, safe water temperatures, daily accounting of residents, supervision,

contingency plans, abuse, criminal records checks, etc.)

Note

□ This standard refers to the sharing of policies and procedures developed and utilized

as evidence of compliance for any of the accommodation standards. There is no

need to re-create policies for this standard.

28(1) An operator shall create and maintain policies and procedures related to the safety

and security of residents to be followed by employees.

Policies and Procedures



Site specific policies and procedures are

created, implemented and current.

Observation of the implementation of

the policies and procedures.


policies and procedures are in

existence and in use by staff. This

information may be found in policy and

procedure manuals, orientation

materials or computerized records.



28(2) An operator shall ensure that all employees are aware of and have access to the

policies and procedures referred to in subsection 1.

Access to Policies and Procedures



Written policies and procedures are

available to all employees.

Observation of location of policies and

procedures in an area accessible to all

employees.


employees are aware of the location of

policies and procedures. This

information may be found in employee

handbooks, orientation materials or

signage.

Electronic version of policies and

procedures are available to all employees.

Observation of location of computer

access points for policies and

procedures in an area accessible to all

employees.


employees are aware of the location of

computer access points policies and

procedures. This information may be

found in employee handbooks,

orientation materials or signage.



Standard 29: Job Descriptions

Intent

Staff must be aware of the expectations of their employment. This standard is intended to

ensure that employees have written job descriptions detailing the scope and responsibilities

of their position.

Definitions

Employee: people employed by the operator, who provide accommodation services,

but does not include health care professionals.

Job qualifications: the requirements that the employee must have to complete the

specified job. This may include education, training, certificates, experience, or other

personal characteristics essential for completion of the job.

Responsibilities: the list of duties or types of duties that the position is expected to

fulfill.

Scope: parameters around the job duties or responsibilities which the position must

abide by (ie. Performing medication reminders, but not assistance).

29(1) An operator shall ensure that a written job description is prepared and made

available for each employee employed in the long-term care accommodation.

Job Description



The operator has written job descriptions

for each position.

Documentation provided may be job

descriptions or task analyses.



Provision of Job Descriptions



The operator makes job descriptions

available to employees.


regarding knowledge of the job

descriptions.


policies and procedures, job

description binders or job duties.

The operator provides employees with

their job description at application or hire.



descriptions.

Documentation provided may be an

application packages, interview

guidelines, commencement packages

or policies and procedures.

The operator provides employees with

their job descriptions at orientation or initial

training.



descriptions.


orientation materials, handbooks or

training materials.

29(2) The job description referred to in subsection 1 must set out

a) the job qualifications,

b) the responsibilities of the position,

and

c) the scope of the position.

Job Description Requirements



The operator provides written job

descriptions covering all points.


job descriptions, job postings or job

duties.



Standard 30: Residents’ Personal Affairs

Intent

Operators must ensure that residents, their representatives, employees and volunteers are

aware of the policies regarding involvement of employees and volunteers in the financial and

non-financial affairs of residents. These policies are intended to protect residents from abuse

and mistreatment.

30(1) An operator shall develop and maintain written policies respecting the involvement

of employees or volunteers in the personal affairs of residents.

Written Processes




regarding the extent of involvement

allowed for employees and volunteers in

residents’ personal affairs.



handbooks, orientation materials, or

training materials.

30(2) The written policies referred to in subsection 1 must at minimum address

a) the accepting of gifts by employees or volunteers from residents, b) the involvement of employees or volunteers in the financial affairs of residents,

including matters relating to powers of attorney, wills and estate planning, and

c) the involvement of employees or volunteers in the non-financial affairs of residents, including matter relating to personal directives, decision-making, and guardianship.

Involvement in Residents Personal Affairs




covering all points.



handbooks, orientation materials, or

training materials.



30(3) The written policies referred to in subsection 1 must be provided to resident, their

representatives, employees and volunteers.

Communication of Processes



The operator provides

residents/representatives/

employees/volunteers with a copy of the

policy referred to in Subsection 1.


policies and procedures.

The operator provides

residents/representatives

employees/volunteers with information

regarding the policy.


handbooks, memos, training materials,

posters or admission agreements.

The operator discussed the policy with


employees/volunteers and documents that

this discussion occurred.

Conversations with


employees/volunteers regarding their

awareness of the policy.


orientation materials, orientation

checklists or meeting minutes.


________________________________________________________________________________________________ © 2010-2015 Government of Alberta LTC Resources 1

Long-term Care Resources

In this section resources are provided to assist long-term care operators to find relevant

information pertaining to the accommodation standards or other applicable legislation. The

resources provided are links to websites that operators may find useful, but are not affiliated

with the Compliance and Monitoring Branch. Utilizing the resources provided is not a

requirement for compliance.

In This Section

Other Governing Legislation 2 Trust Accounts 6

Building Code Requirements 2 Corporate Status 7

Safety Requirements 2 Water Temperature 7

Maintenance Requirements 3 General Information 7

Environmental Requirements 3 Information Respecting the Long-

term Care Accommodation

8

Personal Choice Services 3 Concerns and Complaints 8

Insurance 3 Criminal Record Check 9

Contracted Services 4 Privacy and Personal Information 9

Social and Leisure Activities 4 Job Descriptions 9

Menu and Nutritional

Requirements

4 Residents’ Personal Affairs 9

Cleaning Requirements 4 Other Provincial Standards 10

Continuation of Services 5 Accommodation Standard 16:

Points to consider when developing

Plans

Appendix

A

Prevention of Abuse 5 Water Temperature Safety: Water

System Examples

Appendix

B

Resident Safety and Security 6

Format Used

Resources are listed under the applicable Standard heading. Resources are not provided for every standard.



Other Governing Legislation

Alberta Safety Services Branch: this branch of Municipal Affairs and Housing

administers the Safety Codes Act.

http://www.municipalaffairs.alberta.ca/am_safety_services.cfm

Alberta Safety Codes Act:

http://www.qp.alberta.ca/574.cfm?page=S01.cfm&leg_type=Acts&isbncln=978077

9723652

Public Health Act:

http://www.qp.alberta.ca/574.cfm?page=P37.cfm&leg_type=Acts&isbncln=978077

9743742

Hospitals Act:

http://www.qp.alberta.ca/574.cfm?page=H12.cfm&leg_type=Acts&isbncln=97807

79746996

Nursing Homes Act:

http://www.qp.alberta.ca/574.cfm?page=N07.cfm&leg_type=Acts&isbncln=07797

05394

Nursing Homes General Regulation:

http://www.qp.alberta.ca/574.cfm?page=1985_232.cfm&leg_type=Regs&isbncln=9

780779723881

Nursing Homes Operation Regulation:


780779735518

Building Code Requirements

Refer to your local municipality bylaws for development and/or building permits.

Permit Information Search: enables searching by municipality to determine who to

contact for fire, building, gas, plumbing or electrical permit.

http://www.municipalaffairs.alberta.ca/cp_permit_information_search.cfm

Safety Requirements

Institutions Regulation: governs requirements for institutions with 4 or more

persons receiving care.


773226044

Snow and Ice Removal Services: Sample of process used by Alberta

Infrastructure.

http://www.infrastructure.alberta.ca/Content/docType486/Production/01_93_51P

MS.doc

http://www.municipalaffairs.alberta.ca/am_safety_services.cfm













http://www.municipalaffairs.alberta.ca/cp_permit_information_search.cfm



http://www.infrastructure.alberta.ca/Content/docType486/Production/01_93_51PMS.doc

http://www.infrastructure.alberta.ca/Content/docType486/Production/01_93_51PMS.doc



Maintenance Requirements

Safety Codes Act and Regulations: provides a link to the Act and the associated

Regulations which govern some aspects of building maintenance.

http://www.qp.alberta.ca/1266.cfm?page=s01.cfm&leg_type=Acts&isbncln=97807

79769773

Technical Resource Centre: Samples of processes used by Alberta Infrastructure

for maintenance of structures. http://www.infrastructure.alberta.ca/3543.htm

Alberta Boilers Safety Association: information regarding education and

legislation related to pressure equipment. http://www.absa.ca/

Environmental Requirements




773226044

Personal Choice Services

Personal Services Regulation: This Regulation under the Public Health Act governs

the requirements of personal service professionals.


779716795

Alberta Health Standards and Guidelines for Barbering and Hairstyling:

Guidelines specific to hairdressers and barbers.

http://www.health.alberta.ca/documents/Standards-Barber-Hairstyling.pdf

Massage Therapist Association of Alberta: information pertaining to practicing

Massage Therapy in Alberta

http://www.mtaalberta.com/?page=103

Health Professions Act : link to the Act and associated Regulations that govern

Health Professionals in Alberta.


779766192

Insurance

Insurance Act:

http://www.qp.alberta.ca/574.cfm?page=i03.cfm&leg_type=Acts&isbncln=978077

9743629

Insurance Bureau of Canada: provides information regarding the insurance

industry and descriptors on types of insurance. http://www.ibc.ca/



http://www.infrastructure.alberta.ca/3543.htm

http://www.absa.ca/





http://www.health.alberta.ca/documents/Standards-Barber-Hairstyling.pdf

http://www.mtaalberta.com/?page=103





http://www.ibc.ca/



Contracted Services

Apprenticeship and Industry Training Act: provides a link to the Act and its

associated Regulations which regulates Trades in Alberta.

http://www.qp.alberta.ca/1266.cfm?page=A42.cfm&leg_type=Acts&isbncln=9780

779752232

Canada Home Builder’s Association: Information on writing a contract.

http://www.hiringacontractor.com/

Social or Leisure Activities

□ See local municipality or community associations for local programming guides.

□ Culture and Community Spirit: cultural events around Alberta.

http://culture.alberta.ca/events/default.aspx

□ Therapeutic Activity Directory: provides a listing of activity ideas.

http://www.recreationtherapy.com/tx/actindex.htm

□ Alberta Therapeutic Recreation Association: Information on the profession of

therapeutic recreation in Alberta.

http://www.alberta-tr.org/pages/home/default.aspx

□ Leisure Information Network: a recreation database has a collection of journals

and books with information relevant to different ages and disability groups.

http://lin.ca/htdocs/about.cfm

Menu and Nutritional Requirements

Health Canada: Eating Well with the Canada Food Guide.

http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php

Alberta Healthy U: information and resources on healthy eating.

http://www.healthyalberta.com/



780779735518

Cleaning Requirements

□ Alberta Infection Prevention and Control Strategy

http://www.health.alberta.ca/documents/IPC-Alberta-Strategy-2008.pdf

□ Alberta Hand Hygiene Strategy

http://www.health.alberta.ca/documents/IPC-Hand-Hygiene-Strategy-2008.pdf

Alberta Infrastructure: sample caretaking services task schedule.

http://www.infrastructure.alberta.ca/Content/docType486/Production/00_01_21_

1PMS.doc



http://www.hiringacontractor.com/

http://culture.alberta.ca/events/default.aspx

http://www.recreationtherapy.com/tx/actindex.htm

http://www.alberta-tr.org/pages/home/default.aspx

http://lin.ca/htdocs/about.cfm

http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php

http://www.healthyalberta.com/



http://www.health.alberta.ca/documents/IPC-Alberta-Strategy-2008.pdf

http://www.health.alberta.ca/documents/IPC-Hand-Hygiene-Strategy-2008.pdf

http://www.infrastructure.alberta.ca/Content/docType486/Production/00_01_21_1PMS.doc

http://www.infrastructure.alberta.ca/Content/docType486/Production/00_01_21_1PMS.doc



Alberta Infection Prevention and Control

http://www.albertahealthservices.ca/ipc/hi-ipc-resource-manual-main-

document.pdf

Continuation of Services

Alberta Emergency Management Agency Resources:

Alberta Emergency Management Agency (1-780-422-9000)

http://aema.alberta.ca/

Alberta’s Emergency Plan:

http://www.aema.alberta.ca/ps_alberta_emergency_plan.cfm

Basic Emergency Management Online Course

http://apsts.alberta.ca/online-courses/

Public Safety Canada: Emergency Preparedness Guide

http://www.getprepared.gc.ca/cnt/rsrcs/pblctns/yprprdnssgd/index-eng.aspx

Health Canada: information on extreme heat events.

http://www.healthycanadians.gc.ca/healthy-living-vie-saine/environment-

environnement/sun-soleil/heat-extreme-chaleur-eng.php

Prevention of Abuse

Alberta Seniors Resources:

Protection for Persons in Care Act

http://www.qp.alberta.ca/1266.cfm?page=P29P1.cfm&leg_type=Acts&isbncln=97

80779749904

Protection for Persons in Care

http://www.health.alberta.ca/services/protection-persons-care.html

Adult Safeguards poster

http://www.health.alberta.ca/documents/PPC-Poster.pdf

Financial abuse of seniors fact sheet

http://www.health.alberta.ca/documents/ElderAbuse-Financial-Abuse-Facts.pdf

Elder abuse prevention resources

http://www.health.alberta.ca/seniors/elder-abuse.html

Abuse reporting phone numbers:

Protection for Persons in Care Reporting Line 1-888-357-9339

Calgary Kerby Elder Abuse Line Phone: 403-705-3250 (24 hours)

Edmonton Seniors Abuse Help Line Phone: 780-454-8888 (24 hours)

Edmonton Elder Abuse Intervention Team: 780-477-2929

http://www.albertahealthservices.ca/ipc/hi-ipc-resource-manual-main-document.pdf

http://www.albertahealthservices.ca/ipc/hi-ipc-resource-manual-main-document.pdf

http://aema.alberta.ca/

http://www.aema.alberta.ca/ps_alberta_emergency_plan.cfm

http://apsts.alberta.ca/online-courses/

http://www.getprepared.gc.ca/cnt/rsrcs/pblctns/yprprdnssgd/index-eng.aspx

http://www.healthycanadians.gc.ca/healthy-living-vie-saine/environment-environnement/sun-soleil/heat-extreme-chaleur-eng.php

http://www.healthycanadians.gc.ca/healthy-living-vie-saine/environment-environnement/sun-soleil/heat-extreme-chaleur-eng.php



http://www.health.alberta.ca/services/protection-persons-care.html

http://www.health.alberta.ca/documents/PPC-Poster.pdf

http://www.health.alberta.ca/documents/ElderAbuse-Financial-Abuse-Facts.pdf

http://www.health.alberta.ca/seniors/elder-abuse.html



Red Deer Helping Elder Abuse Reduction Resource Information Line: 403-346-6076

or 1-877-454-2580 toll-free (24 hours)

Lethbridge Senior Citizens Organization Phone: 403-320-2222 (Ext 25)

Medicine Hat Community Response to Abuse and Neglect of Elders (CRANE)

Phone: 403-529-4798 (24 hours)

St. Albert Stop Abuse in Families: 780-459-0433

Strathcona County Elder Abuse Line: 780-464-7233

Alberta Elder Abuse Awareness Network: Knowledge, resources and tools about

elder abuse amongst people who work with seniors. www.albertaelderabuse.ca

Government of Canada: Elder abuse information.

http://www.seniors.gc.ca/eng/pie/eaa/elderabuse.shtml

Royal Canadian Mounted Police

http://www.rcmp-grc.gc.ca/

Legal Resource Centre: Abuse of Older Adults.

http://www.law-faqs.org/docs/AbuseThirdEdAugFINAL.pdf

Elder Advocates Of Alberta Society

http://elderadvocates.ca/what-is-elder-abuse/

Alberta Council on Aging: A service provider’s resource manual for elder abuse in

Alberta.

http://www.acaging.ca/uploads/files/Program%20PDF/ACA%20Multicultural%2

0Booklet--Text-FINAL-2012.pdf

Resident Safety and Security

See manufacturer’s information for security, emergency call and communication

systems.

Alzheimer’s Society: information on searching for missing persons with dementia.

http://www.alzheimer.ca/en/We-can-help/Resources/Alzheimer-Society-

brochures-and-publications

Trust Accounts



780779735518

http://www.albertaelderabuse.ca/

http://www.seniors.gc.ca/eng/pie/eaa/elderabuse.shtml


http://www.law-faqs.org/docs/AbuseThirdEdAugFINAL.pdf

http://elderadvocates.ca/what-is-elder-abuse/

http://www.acaging.ca/uploads/files/Program%20PDF/ACA%20Multicultural%20Booklet--Text-FINAL-2012.pdf

http://www.acaging.ca/uploads/files/Program%20PDF/ACA%20Multicultural%20Booklet--Text-FINAL-2012.pdf

http://www.acaging.ca/files/helpinghandsenglish.pdf



http://www.alzheimer.ca/en/We-can-help/Resources/Alzheimer-Society-brochures-and-publications

http://www.alzheimer.ca/en/We-can-help/Resources/Alzheimer-Society-brochures-and-publications





Corporate Status

Business Corporations Act

http://www.qp.alberta.ca/574.cfm?page=B09.cfm&leg_type=Acts&isbncln=978077

9743476

Cooperatives Act

http://www.qp.alberta.ca/574.cfm?page=C28P1.cfm&leg_type=Acts&isbncln=978

0779743513

Companies Act

http://www.qp.alberta.ca/574.cfm?page=c21.cfm&leg_type=Acts&isbncln=978077

9746361

Partnership Act


9744442

Societies Act


6936

Water Temperature

Power Engineers Regulation under the Safety Codes Act.


779736435

Alberta Building Code: link to purchase the Code.

http://www.qp.alberta.ca/1266.cfm?page=2007_117.cfm&leg_type=Regs&isbncln=

9780779769070




773226044

Arjo Therapeutic Tubs: manufacturer of therapeutic tubs.

http://www.arjoHuntleigh.com

Apollo: manufacturer of therapeutic tubs.

http://www.apollobath.com/

General Information

□ Alberta Supports: provincial information about programs and services

http://www.programs.alberta.ca/Living/13765.aspx?Ns=13705&N=770

□ Active Living Coalition for Older Adults: Resource Directory 2008

http://www.alcoa.ca/e/pdf/resource_directory_2008.pdf

















http://www.arjohuntleigh.com/

http://www.apollobath.com/

http://www.programs.alberta.ca/Living/13765.aspx?Ns=13705&N=770

http://www.alcoa.ca/e/pdf/resource_directory_2008.pdf



Alberta Government Programs and Services: Community Resources

http://www.programs.alberta.ca/Living/9546.aspx?Ns=9551+9574&N=770

Seniors Association of Greater Edmonton (SAGE)

http://www.mysage.ca/about-us

Seniors Programs and Services Guide

http://www.seniors.alberta.ca/documents/Seniors-ProgramsServicesGuide.pdf

Senior Financial Assistance: link to information on special needs assistance, dental

assistance and optical assistance.

http://www.seniors.alberta.ca/seniors/financial-assistance.html

Alberta Aids to Daily Living (AADL)

http://www.health.alberta.ca/services/aids-to-daily-living.html

Service Canada: Services for seniors.

http://www.servicecanada.gc.ca/eng/audiences/seniors/index.shtml

Assured Income for the Severely Handicapped (AISH).

http://humanservices.alberta.ca/disability-services/aish.html

Alberta Continuing Care Association: http://www.ab-cca.ca/

Information Respecting the Long-term Care Accommodation

Nursing Homes Act:


05394

Nursing Homes General Regulation:


780779723881



780779735518

Sample residential service agreements:

http://www.health.state.ny.us/facilities/assisted_living/docs/model_residency_agre

ement.pdf

http://fourwindscommunitynh.org/Parents/Res%20Svcs%20Agrmt-Example.pdf

http://www.manorhills.net/pdf/admission_agreement.pdf

Concerns and Complaints

□ Alberta Health Services: Feedback form.

https://www.albertahealthservices.ca/273.asp

http://www.programs.alberta.ca/Living/9546.aspx?Ns=9551+9574&N=770

http://www.mysage.ca/about-us

http://www.seniors.alberta.ca/documents/Seniors-ProgramsServicesGuide.pdf

http://www.seniors.alberta.ca/seniors/financial-assistance.html

http://www.health.alberta.ca/services/aids-to-daily-living.html

http://www.servicecanada.gc.ca/eng/audiences/seniors/index.shtml

http://humanservices.alberta.ca/disability-services/aish.html

http://www.ab-cca.ca/







http://www.health.state.ny.us/facilities/assisted_living/docs/model_residency_agreement.pdf

http://www.health.state.ny.us/facilities/assisted_living/docs/model_residency_agreement.pdf

http://fourwindscommunitynh.org/Parents/Res%20Svcs%20Agrmt-Example.pdf

http://www.manorhills.net/pdf/admission_agreement.pdf

https://www.albertahealthservices.ca/273.asp



Criminal Record Check

□ Protections for Persons in Care Act


80779749904

Royal Canadian Mounted Police


BackCheck

http://www.backcheck.net/

Privacy and Personal Information

Freedom of Information and Protection of Privacy Act

http://www.qp.alberta.ca/574.cfm?page=F25.cfm&leg_type=Acts&isbncln=978077

9743568

Freedom of Information and Protection of Privacy (FOIP) Guidelines and

Practices Manual 2009

http://www.qp.alberta.ca/570.cfm?frm_isbn=9780778585633&search_by=link

Personal Information Protection Act

http://pipa.alberta.ca/index.cfm?page=legislation/act/index.html

Health Information Act


79743575

Personal Information Protection and Electronic Documents Act (PIPEDA)

http://laws.justice.gc.ca/eng/P-8.6/page-1.html

Guide to PIPEDA

http://www.priv.gc.ca/information/02_05_d_08_e.cfm

Nursing Homes Act:

http://www.qp.alberta.ca/574.cfm?page=N07.cfm&leg_type

=Acts&isbncln=0779705394

Job Descriptions

□ University of Alberta: guidelines for writing job descriptions.

http://www.hrs.ualberta.ca/en/HiringandManaging/JobDesign/APO/WritingPositi

onDesc.aspx

Residents’ Personal Affairs

Adult Guardianship and Trusteeship Act

http://www.qp.alberta.ca/574.cfm?page=A04P2.cfm&leg_type=Acts&isbncln=978

0779743797




http://www.backcheck.net/



http://www.qp.alberta.ca/570.cfm?frm_isbn=9780778585633&search_by=link

http://pipa.alberta.ca/index.cfm?page=legislation/act/index.html



http://laws.justice.gc.ca/eng/P-8.6/page-1.html

http://www.priv.gc.ca/information/02_05_d_08_e.cfm

http://www.qp.alberta.ca/574.cfm?page=N07.cfm&leg_type%20=Acts&isbncln=0779705394

http://www.qp.alberta.ca/574.cfm?page=N07.cfm&leg_type%20=Acts&isbncln=0779705394

http://www.hrs.ualberta.ca/en/HiringandManaging/JobDesign/APO/WritingPositionDesc.aspx

http://www.hrs.ualberta.ca/en/HiringandManaging/JobDesign/APO/WritingPositionDesc.aspx





Personal Directives Act

http://www.qp.alberta.ca/574.cfm?page=p06.cfm&leg_type=Acts&isbncln=978077

9747368

Personal Directive Registry

http://humanservices.alberta.ca/guardianship-trusteeship/opg-personal-directives-

registry.html

Powers of Attorney Act


9743735

Other Provincial Standards

□ Continuing Care Health Service Standards:

http://www.health.alberta.ca/services/continuing-care.html



http://humanservices.alberta.ca/guardianship-trusteeship/opg-personal-directives-registry.html

http://humanservices.alberta.ca/guardianship-trusteeship/opg-personal-directives-registry.html



http://www.health.alberta.ca/services/continuing-care.html


________________________________________________________________________________________________ © 2010-2015 Government of Alberta Appendix A 1

Resource ~ Appendix A

Accommodation Standard 16: Points to Consider when Developing Plans

This section outlines some scenarios that could occur at an accommodation that may result in the activation of a contingency plan. This section is not intended to be used as a template to create a plan nor is it considered to be best practice. Utilizing this section is not a requirement for compliance. This section is a resource only when developing a contingency plan for Accommodation Standard 16.

In This Section

Loss of electrical power 2 Loss of water 4 Loss of natural gas 5 Loss of telecommunications 6 Breakdown of essential equipment 7 Weather events and naturally occurring emergencies 8 Staff shortages / employment disputes 9 Evacuation / relocation 10 Disruption of meal service 11 Disruption of safety and security service 12 Disruption of cleaning service 13 Disruption of laundry/linen service 14 Disruption of maintenance service 15

Format Used

Questions to consider are listed under each emergency / disruption type. Questions will not apply to all accommodations, nor are they inclusive of all points an operator may need to consider.

Description of Headings Used

□ At the start of an outage: questions related to tasks that may need to be completed first following a disruption

□ Determining cause of the disruption: questions related to determining possible scenarios that may lead to a disruption

□ Sheltering in place: questions related to continuing to provide services at the same location

□ Evacuation/relocation: questions related to determining when or if evacuation is necessary

□ Special Considerations: questions specific to certain scenarios within the disruption

□ Recovery: questions related to recommencing with full service



Loss of Electrical Power

At the start of an outage:

Consider

Who is responsible for ensuring that all residents are safe and accounted

for?

Who is responsible to determine the cause/potential length of the outage?

What key contacts need to be informed of the disruption?

Sheltering in Place:

What equipment relies on power to operate?

Consider

□ Heating system

□ Cooling system

□ Hot water heating

□ Communication

devices

□ Security systems

□ Fire alarm system

□ Emergency call

systems

□ Phones

□ IT equipment

□ Safety and security

equipment

□ Sanitation

equipment

□ Food preparation

equipment

□ Fridges, coolers

and freezers

□ Food service

equipment

□ Elevator

□ Washer and dryers

□ Cleaning

equipment

□ Oxygen

concentrators

□ Medical equipment

□ Resident care

equipment

□ Other:

Consider

If that equipment is not operational what services/functions are affected?

□ Meal service

□ Housekeeping service

□ Laundry service

□ Safety and security service

□ Resident care

□ Communications

□ Alerts/warnings

□ Temperature control

□ Resident mobility

□ Access to resident information

□ Other:

PLAN For each identified service/function that may be lost, develop a

contingency plan that reduces the impact of the loss/disruption for the

residents.

Evacuation/relocation – See Evacuation/relocation

Consider At what point would evacuation/relocation be considered?

Special Considerations: Battery Back-ups

Consider

What equipment/devices have a battery backup?

How long will the battery backup last for?

What is the plan if the outage extends past the battery life of the

equipment/devices?



Special Considerations: Generators

Consider

Is there a generator on site?

□ Yes □ No

If an off-site generator will be used, where and how is it accessed?

How does the generator start?

□ Automatically □ Manually

What if it does not start? Who starts the generator?

How is it started?

How long will the generator provide power for?

Which plugs/equipment will have power while the generator is operating?

Where is additional fuel ordered from?

What is the plan if the generator fails?

What is the plan for any necessary services/equipment that does not receive generator power?

Recovery

Consider When service is restored, who is responsible to ensure that all equipment becomes operational again?



Loss of Water


Consider


If the loss is internal, who should be contacted for repair?



Consider

What equipment/services rely on water to operate?

□ Heating system

□ Cooling system


□ Toilet

□ Bath/shower/sinks

□ Sanitation

equipment (Food)


equipment

□ Food service

equipment

□ Clothes washer

□ Housekeeping

□ Resident care

equipment

□ Other:

If that equipment is not operational what services/functions are affected?

□ Meal service


□ Laundry service

□ Resident care


□ Sanitation

□ Hydration

□ Other:

PLAN For each identified service/function that may be affected develop a

contingency plan that reduces the impact of the loss/disruption for the

residents.



Special Considerations: Water Storage

Consider

Is extra water stored on site?

□ Yes

How much extra water is

stored on site?

Where is the water stored?

□ No

Where can water be

accessed?

Are any agreements in place

for priority delivery?

What is the plan until the

water arrives?

When the water arrives,

where will it be stored?

What should the water be used for during an outage?

What is the plan when the water supply is depleted?

Recovery

CONSIDER When service is restored, who is responsible to ensure that all equipment

becomes operational again?



Loss of Natural Gas


Consider





Consider

What equipment relies on natural gas to operate?

□ Heating system

□ Cooling system

□ Fireplace



equipment

□ Clothes dryers

□ Other:

If that equipment is not operational what services/functions are

lost/affected?

□ Meal service

□ Laundry service


□ Resident care

□ Other:

PLAN For each identified service/function that may be lost develop a

contingency plan that reduces the impact of the loss for the residents.



Recovery

Consider When service is restored, who is responsible to ensure that all equipment




Loss of Telecommunications


Consider





Consider

What telecommunication services are used?

□ Phone (landline)

□ Phone (cell)

□ Cable

□ Internet

□ Intranet

□ Computer services

What equipment relies on telecommunications to operate?

□ Communication devices



□ Emergency call systems

□ Phones

□ Fax

□ Safety and security equipment

□ Computer equipment

□ Resident care equipment

□ Other:

If that equipment is not operational what services/functions are lost/affected?


□ Resident care

□ Access to information

□ Communications

□ Alerts/warnings


□ Other:





Special Considerations: Accessing Information

Consider

What information may be inaccessible without a computer, internet or

intranet?

□ Resident care information

□ Contingency plans

□ Contact lists

□ Supply lists

□ To do lists

□ Policies and procedures

□ Forms

□ Emails

□ Resources

□ Other:

What information is essential for employees to have access to in an

emergency?

PLAN For each identified type of crucial information, where can the

information also be found (paper based)?

Recovery

Consider When service is restored, who is responsible to ensure that all equipment




Breakdown of Essential Equipment


Consider

Who is responsible for ensuring that all residents are safe, accounted for

and are aware of any restrictions due to the breakdown?


Who is responsible to make or arrange for repairs to equipment?



Consider

What equipment is contained within the accommodation?

□ Heating system

□ Cooling system


□ Water pumps

□ Elevator

□ Generator

□ Communication devices



□ Emergency call systems

□ Phones

□ Safety and security equipment

□ Sanitation equipment

□ Food preparation equipment

□ Fridges, coolers and freezers

□ Food service equipment

□ Washer and dryers

□ Cleaning equipment

□ Grounds maintenance equipment

□ Transportation equipment


□ Lifts

□ Therapeutic tubs

□ Oxygen concentrators

□ Other:

Of the equipment listed which are essential to maintain services to residents?

If that equipment is not operational what services/functions are lost/affected?

□ Meal service


□ Laundry service


□ Resident care

□ Emergency services

□ Communications

□ Alerts/warnings

□ Maintenance services



□ Other:

PLAN For the equipment identified as essential, develop a contingency plan

that reduces the impact of the loss for the residents.

Consider Who are the appropriate service personnel to repair/replace the equipment?

Does the contingency plan change seasonally (summer vs. winter)?



Special Considerations: Back-ups / System Redundancies

Consider

What equipment has a battery backup?

Which systems have redundancies built into them, so they will continue to

operate even with the failure of one part/piece of equipment?

What special considerations may be needed when running on battery back-

up or with reduced equipment?



Weather Events and Natural Occurring Emergencies

Determining what natural occurring emergencies may impact your accommodation:

Consider

What natural occurring emergencies have or may occur in your area?

□ Thunderstorm

□ Hailstorm

□ Tornado

□ Flood

□ Blizzard

□ Ice storm

□ Avalanche

□ Extreme cold

□ Heat wave

□ Wildfire

□ Other:

In what situations would the accommodation:

□ Shelter in place? □ Evacuate?

What key contacts need to be informed of the emergency/event?

Sheltering in Place

Consider

What is the safest place at the site for the residents to be during the event?

Do modifications to routines/structure need to be made for the duration of

the event?

What disruptions may also occur as a result of the emergency?

□ Loss of power

□ Loss of water

□ Loss of natural gas

□ Loss of

telecommunication

s

□ Site isolation

□ Staff shortage

□ Limited supplies

□ Inaccessibility of

emergency

services

□ Loss of

heating/cooling

□ Other:

With these additional disruptions what services/functions may be affected?

□ Meal service


□ Laundry service


□ Resident care

□ Communications

□ Alerts/warnings



□ Other:




Consider

At what point would evacuation/relocation be considered?

What if evacuation/relocation was not possible to be completed as planned

(eg. Roads impassable)?

Recovery

Consider Once the emergency/weather event has passed what is necessary to return

to full services and reduce further damage?



Staff Shortage/Employment Disputes

Determining potential causes of a staff disruption

Consider

For what reasons may a staff shortage be likely to occur?

□ Lock out

□ Work to rule

□ Strike

□ Pandemic/sickness

□ Site isolation

□ Failure to fill

positions

□ Weather

emergencies

□ Other:

Will the staff disruption result in:

□ No staff

□ Reduced staff

□ No replacement staff

Do any employees/positions have specialized knowledge that is essential

for the continued operation of the accommodation?

Are staff cross-trained for these positions/specialized knowledge? Is written

information available for reference?

Will volunteers be used in any capacity and if so, who coordinates this

assistance and what training or support would be required?

Sheltering in Place

Consider

What services are offered by the accommodation?

□ Meal service

□ Housekeeping

service

□ Laundry service

□ Safety and security

service

□ Maintenance

service

□ Resident care

□ Social and leisure

activities

□ Transportation

service

□ Medication service

□ Other

What services are essential to continue at the same level that is being

offered?

What services may be offered at a reduced level?

What services may be discontinued for the duration of the shortage?




Consider

Will family members / representatives be asked to take residents home?

Who will be responsible for contacting family/representatives and making

arrangements?

What is the plan for those residents not staying with family/representatives?

Recovery

Consider What services are essential to recover first?

Who will make contact with residents staying with family/representatives?



Evacuation / Relocation

Preparing

Consider

Where is the relocation site?

Who has keys for the relocation site?

Will residents stay at this site or be transported to another site for

continuation of services?

Does the relocation site meet the needs of the residents?

Are multiple relocation sites necessary for residents with differing needs?

What key contacts need to be informed of the evacuation/relocation?

Will volunteers be used in any capacity and if so, who coordinates this

assistance and what training or support would be required?

Evacuation

Consider

If able, what items should be brought with residents to the evacuation site?

□ Medications

□ Mobility aids

□ Care equipment

□ Care items

□ Food (including special diets)

□ Clothing/Toiletries

□ Linens/blankets

□ Resident information (including important contacts)

How will the residents be transported to the relocation site?

If all residents are not on site who will be responsible for ensuring that the

remaining residents are brought to the relocation site?

Will some residents go home with family/representatives?

Who will track which residents have left with family/representatives?

Who will inform families / staff where the relocation site is situated?

Relocation Site

Consider

What facilities/services are available at the relocation site?

□ Bathrooms

□ Accessible site

□ Beds

□ Linens and towels

□ Telecommunications equipment


□ Safety and security services

□ Cooking facilities

□ Food preparation, serving and eating equipment

□ Mobility equipment

□ Sanitation equipment

□ Laundry equipment

What supplies are necessary to continue offering services at the relocation site?

How will these supplies be made available/accessible at the relocation site?

Are additional staff/volunteers required at the relocation site to provide services?

What services are unavailable at the relocation site that will need to be arranged for?

What services may be offered at a reduced level at the relocation site?

What services may be discontinued for the duration of the relocation?

PLAN For each identified service/function that may be lost develop a contingency plan that reduces the impact of the loss for the residents.



Disruption of Meal Service

Determining the cause of the disruption:

Consider

Consider potential causes of a disruption to meal services:

□ Staff shortage

□ Site isolation

□ Equipment

breakdown

□ Loss of utilities

□ Other:


Consider

How much food/beverages is kept on site?

□ Less than one day

□ 24-48 hours

□ 72 hours

□ 72 hours +

Do changes need to be made on how much food/beverages are stored on

site?

Will alternate food suppliers need to be used during the disruption?

What changes need to be made to the menu / meal service so that

equipment/utilities are not needed?

Will catering, take out or eating out be required?

Who will be responsible for paying for eating out / take out?

PLAN For each identified disruption, develop a contingency plan that

reduces the impact of the loss for the residents.

Special Considerations: Alternate food preparation sites

Consider

Is there an alternate site available where meals can be prepared?

Have any arrangements been made to use the alternate site?

How will meals be transported and appropriate temperatures maintained?

What if transportation of food is not possible (eg. Roads are impassable)?

Special Considerations: Equipment

Consider Is there alternate equipment on site that can be used?

Can replacement equipment be brought to the site?

Recovery

Consider Once the disruption is resolved, what steps are necessary to return to full

meal service?



Disruption of Safety and Security Service


Consider

Consider potential causes of a disruption to safety and security services:

□ Staff shortage


□ Breakdown of equipment

□ Other:

At the start of a disruption:

Consider

Who is responsible for ensuring that all residents are safe and accounted

for?



Consider

What safety and security services are offered?

□ Accounting for residents

□ Nurse call

□ Pendant

□ Call bells

□ Security system

□ Security cameras

□ Wanderguard

□ Roam alert

□ Fire alarm

□ Door alarm

□ Bed alarm

□ Wheelchair alarm

□ Other:

Which safety and security services are essential to continue?



Consider

How will the safety and security services be performed in the absence of

electronic alarms/monitors?

Will additional staff/volunteers be needed?

Who is responsible for arranging for additional staff or volunteers?

Who is responsible for arranging for necessary repairs?

Recovery


services?



Disruption of Cleaning Service


Consider

Consider potential causes of a disruption to cleaning services:

□ Staff shortage


□ Site isolation / pandemic


□ Other:


Consider

What cleaning services are offered?

□ Regular room

cleaning

□ Thorough room

cleaning

□ Daily room cleaning

□ Kitchen sanitizing

□ Common area

cleaning

□ Office cleaning

□ Staff area cleaning

□ Spots/spills

cleaning

□ As needed cleaning

□ Other:

What cleaning services are essential to continue?

What methods of cleaning will be changed during the disruption?

What cleaning services can be stopped until the disruption is resolved?

PLAN For each identified service that may be lost develop a contingency

plan that reduces the impact of the loss for the residents.

Consider

Is there back-up equipment?

Are there alternate staff or volunteers that can be used to continue the

cleaning service?

Can a cleaning service be hired?

Recovery


services?



Disruption of Laundry/Linen Service


Consider

Consider potential causes of a disruption to laundry/linen services:

□ Staff shortage




□ Other:


Consider

How often are laundry/linen services offered?

□ Daily (Sat – Sun)

□ Weekdays (Mon-Fri)

□ Occasional weekdays

□ Weekends

□ Weekly

□ As needed

□ Other

How much extra linen is kept on site?

Considering the supply of linens and frequency of laundry services, how

many days can laundry service be discontinued?

If laundry/linen service is discontinued, how will soiled laundry/linens be

stored during the disruption?



Consider Is there back-up equipment at the site that may be used?

Who is responsible for arranging for repairs to equipment, if required?

Special Considerations: External Providers

Consider

Is there a suitable location for laundry to be sent out to?

Will the alternate site pick up and deliver and will arrangements need to be

made to transport the linens/laundry?

Is it necessary to enter into an agreement with the alternate laundry service

provider prior to the disruption?

Will families/representatives be asked to take laundry home to launder?

Recovery


services?



Disruption of Maintenance Service


Consider

Consider potential causes of a disruption to maintenance services:

□ Staff not on site (external oversight of the site)

□ Staff vacation / other leaves


□ Staff shortage

□ Other:


Consider

What maintenance services are essential to continue?

□ Snow and ice removal

□ Basic corrective maintenance

□ Monitoring equipment

□ Emergency response

□ Monitoring temperatures

□ Daily checks

□ Other

PLAN For each identified disruption, develop a contingency plan that reduces the impact of the loss for the residents.

Consider

Does cross-training need to occur for the continuation of services? Is written reference material available?

What tasks can only be completed by qualified personnel?

Do alternate suppliers/contractors need to be arranged for the completion of maintenance services?

Who is responsible on an on-call basis?

Is there any emergency response role that is specific to maintenance (fire marshal)?

Do maintenance staff have essential items, such as keys to relocation sites, transportation equipment or rooms in the accommodation?

Do maintenance staff have essential information such as passwords or access codes to electronic monitoring equipment or key areas?

Recovery

Consider Once the disruption is resolved, what steps are necessary to return to full services?


_________________________________________________________________________________________________© 2010-2015 Government of Alberta Appendix B 1

Resources ~ Appendix B

Water Temperature Safety ~ Water System Examples

Mixing Valves Installed at all Faucets This is an ideal system to allow for the maintenance of a gas, oil fired or electric storage type

water heater at 60C or higher and the temperature from the faucets at 49C or lower.

Note: Faucets that have a scald-free device (often seen in single lever faucets), are

considered a mixing valve for this example.

21(1) Temperature measurement requirements

Temperature needs to be taken from all faucets in the accommodation

Instantaneous Water Heater This is an ideal system for maintaining temperatures safely without the installation of mixing

valves. An instantaneous water heater can be safely operated at 49C.


Temperature needs to be taken from any faucet in the accommodation

Mixing Valve Installed at the Source

MixingValve

Mixing valve installed at each faucet

MixingValve

All faucets throughout the accommodation

http://www.amazon.ca/Rheem-RTE-13-Electric-Tankless/dp/B003UHUSGQ?sa=X&ved=0CDEQ9QEwDmoVChMI9Iu_icf7xgIVwSmICh23Rwup



This system allows the gas, oil fired or electric storage type water heater to be maintained at

60C and the water from faucets at 49C or lower. This system has increased risks, as the

water within the lines is not maintained at 60C. Risk mitigation to ensure that water in not standing for extended periods of time is recommended.



No Mixing Valves This system does not allow the gas or oil fired storage type water heater to be maintained at

60C. In order to maintain water from faucets at 49C, the storage type water heater

temperature must also be reduced. This system has increased risks as the water in the tank

and in the lines is not maintained at 60C. Risk mitigation to ensure that water is not

standing for extended periods of time and the tank is fully drained regularly is

recommended.

Note: This example cannot be utilized for electric storage water heaters, as per the National

Plumbing Code of Canada (2.6.1.12, 2010): ‘Thermostat controls for electric storage-type

service water heaters shall be set at a temperature of 60C.’



Mixing Valve Installed on Select Areas Only

MixingValve All faucets throughout the

accommodation

All faucets throughout the accommodation



This system does not allow the gas or oil fired storage type water heater temperature to be

maintained at 60C. In order to maintain water from faucets at 49C, the storage type water

heater temperature must also be reduced. This will compromise the function of any installed

mixing valves. This system has increased risks as the water in the tank and in the lines is not

maintained at 60C. Risk mitigation to ensure that water is not standing for extended

periods of time and the tank is fully drained regularly is recommended.

Note: Faucets that have a scald-free device (often seen in single lever faucets), are

considered a mixing valve for this example.

This example cannot be utilized for electric storage water heaters, as per the National

Plumbing Code of Canada (2.6.1.12, 2010): Thermostat controls for electric storage-type

service water heaters shall be set at a temperature of 60C.


Temperature needs to be taken at each mixing valve location and from any other

faucet in the accommodation

Re-Circulated Systems

All of the above examples also apply to faucets located in systems utilizing re-circulation.

These systems may be most appropriately protected when mixing valves are installed at

faucets. Systems without mixing valves require caution to ensure that the minimum

temperature of hot water storage tanks are maintained and consistent and safe temperatures

are maintained at the outlet of each faucet.

MixingValve

Mixing valve installed – select areas only


_________________________________________________________________________________________________© 2010-2015 Government of Alberta Forms 1

Forms In this section the forms to be used in both supportive living and long-term care accommodations are provided.

In This Section

Forms – Form names and electronic links are listed below. All current and updated forms can be found online at: http://www.health.alberta.ca/services/continuing-care-forms.html Applications

Eligibility for Licensing of Supportive Living Accommodation

http://www.health.alberta.ca/documents/CC-Supportive-Living-Eligibility.pdf

Supportive Living Licence Application

http://www.health.alberta.ca/documents/CC-Supportive-Living-Application.pdf

Long-Term Care Certificate Application


Checklists

Supportive Living Inspection Preparation Checklist

http://www.health.alberta.ca/documents/CC-Supportive-Living-Standards-2010.pdf

Long-term Care Inspection Preparation Checklist

http://www.health.alberta.ca/documents/CC-Long-Term-Care-Standards-2010.pdf

Complainant Decision Appeal Form


Reportable Incident Form

http://www.health.alberta.ca/documents/CC-Reportable-Incident-Form.pdf


http://www.health.alberta.ca/documents/CC-Supportive-Living-Eligibility.pdf

http://www.health.alberta.ca/documents/CC-Supportive-Living-Application.pdf


http://www.health.alberta.ca/documents/CC-Supportive-Living-Standards-2010.pdf

http://www.health.alberta.ca/documents/CC-Long-Term-Care-Standards-2010.pdf


http://www.health.alberta.ca/documents/CC-Reportable-Incident-Form.pdf


_________________________________________________________________________________________________ © 2010-2015 Government of Alberta Reportable Incidents 1

Reportable Incidents

In this Section

Both the Accommodation Standards and the Health Service Standards include a reportable

incident component. To streamline this process for those operators that must follow both

set of standards a coordinated Reportable Incident approach has been taken. In determining

what form, example sheet and decision guide to use, please determine if you are:

Health Funded: Includes accommodations or services that receive funding from

Alberta Health Services. Includes Long-term care, designated supportive living,

personal care homes, family care homes, home care and home living services.

Non-Health Funded: Includes all other accommodations licensed under the

Supportive Living Accommodation Licensing Act that are not funded by Alberta Health

Services. Includes lodges, private assisted living, group homes (private and funded by

Persons with Developmental Disabilities).

Note

For fillable PDF form, please see: http://www.health.alberta.ca/services/continuing-care-forms.html

The form will require the user to click either the Health-Funded or the Non-Health Funded

checkbox prior to completing the form. Upon doing this, the appropriate step-by-step

instructions will appear.

The following materials are provided to assist operators to determine what incidents are

reportable.

Decision Guide: Health Funded Examples: Health Funded The following decision guides and examples can also be found on-line at: http://www.health.alberta.ca/documents/CC-Reportable-Incidents-Decision-Process.pdf



Did the incident occur due to an assault or aggression?

Does the incident relate to the accommodation or health service standards and result in one of the following:

Resident death or

serious harm

Did the incident occur due to an error or omission in the

provision of accommodation or health services?

Did the incident occur due to the accommodation, grounds or

equipment being in disrepair, in an unsafe condition or used in an

unsafe manner?

Yes

No Yes, Report

Yes, Report No, Not Reportable

Resident/Client unaccounted for

Did the resident’s absence occur outside the limits set out in their assessment, individual

plan or accommodation policy?

Did the resident’s absence occur as result of equipment

or technology failure?

Did the resident’s absence occur as result of an error or

omission of personnel?

Yes

No

No

Yes, Report

Yes, Report


Unplanned activation of a

contingency plan

Did the activation occur due to severe weather?

Did the activation occur due to a loss of utilities?

Did the activation occur due to a breakdown of essential equipment?

Did the activation occur due to a staff disruption?

Yes

No

No

No

Yes, Report

Yes, Report

Yes, Report


Extensive damage to the

accommodation

Did the damage affect the ability to provide accommodation or

health services?

Did the damage require residents to be relocated

(off site or within the site)?

Yes

No Yes, Report


Is the accommodation, grounds or equipment in disrepair or in an unsafe

condition?

No Yes, Report

Reportable Incidents are to be submitted to Alberta Health within two business days by the operator. Forms can be completed and submitted electronically at: http://www.health.alberta.ca/services/continuing-care-forms.html

Serious Harm: Physical or psychological injury which is life threatening and/or traumatic to the individual Extensive damage: damage to the extent that the ability of the operator to continue to provide accommodation services and a safe and secure environment is affected

No Yes, Report

Reportable Incident Decision Guide: Health Funded Accommodations

Did the activation result in an evacuation?

No Yes, Report


Health Funded Reportable Incident Examples

Resident Death or Serious Harm Resident/Client Unaccounted for

Unplanned Activation of Contingency Plan

Extensive Damage to the Accommodation

Examples of reportable incidents may include, but is not limited to:

Error or Omissions o Falls* (witnessed & unwitnessed) o Medication Errors (unsecured

medications being ingested, missed medications, wrong client/dosage/medication/route/time)

o Risk agreement or care plan not adhered to

o Choking o Burns, scalding o Ingestion of chemicals/toxins o Sharps injury o Unexpected death

Resident absence o Unexplained

resident absence o Abnormal extended

absence of a resident o Elopement

Loss of utilities o Power o Gas o Water o Telephone Service

Services affected o Flood (water main

break, sprinkler system failure)

o Damage to section of building

Breakdown of Essential Equipment

o Loss of heating equipment

o Loss of service equipment

o Loss of elevator

Assault or Aggression o Self harm o Aggressive behaviour to others o Sexual Assault o Attempted suicide

Equipment or technology failure o Failure of door

alarms, roam alerts, or wanderguard

Staff Disruption o Strike o Site isolation o Shortage

Relocation o Flood o Fire o Gas leak o Overall building

damage Evacuation

o Full/Partial

Accommodation, Grounds, Equipment in disrepair/unsafe

o Equipment malfunction o Operator error (in use of equipment) o Ice or snow that has not been removed o Injury due to disrepair o Tripping hazards

Error or omission of personnel o Failure of daily

accounting systems o Failure of site

security

Severe Weather o Tornado o Summer or winter

storms o Excessive Heat

Unsafe conditions o Roof leak/collapse o Damage to section

of building

*Fall: unintentionally coming to rest on the ground, floor or other lower level (definition as per AHS policy)